CAM 206

Urine Culture Testing for Bacteria

Category:Laboratory   Last Reviewed:August 2018
Department(s):Medical Affairs   Next Review:August 2019
Original Date:December 2018    

Description 
Bacteriuria is the presence of bacteria in the urine. Urinary tract infections (UTIs) can occur in the urinary system and can be either symptomatic or asymptomatic. UTIs can include cystitis, an infection of the bladder or lower urinary tract; pyelonephritis, an infection of the upper urinary tract or kidney; urosepsis; urethritis; and male-specific conditions, such as bacterial prostatitis and epididymitis (Bonkat et al., 2018; Hooton & Gupta, 2018). Typically, in an infected person, bacteriuria and pyuria (the presence of pus in the urine) are present and can be present in both symptomatic and asymptomatic UTIs. A urine culture can be performed to determine the presence of bacteria and to characterize the bacterial infection (Meyrier, 2017).  

Urinary tract infections (UTIs) can be either symptomatic or asymptomatic and can also be classified as uncomplicated or complicated. Uncomplicated UTIs are "acute, sporadic or recurrent lower (uncomplicated cystitis) and/or upper…UTI, limited to non-pregnant, pre-menopausal women with no known relevant anatomical and functional abnormalities within the urinary tract or comorbidities… All UTIs which are not defined as uncomplicated [are complicated UTIs]. Meaning, in a narrower sense, UTIs in a patient with an increased chance of a complicated course: i.e., all men, pregnant women, patients with relevant anatomical or functional abnormalities of the urinary tract, indwelling urinary catheters, renal diseases, and/or with other concomitant immunocompromising diseases, for example, diabetes (Bonkat et al., 2018)." For complicated UTIs, Escherichia coli is the most common cause; however, "other uropathogens include other Enterobacteriaceae (such as Klebsiella spp and Proteus spp), Pseudomonas, enterococci, and staphylococci (methicillin-sensitive Staphylococcus aureus [MSSA] and methicillin-resistant S. aureus [MRSA]) (Hooton & Gupta, 2018)." Even though both bacteriuria and pyuria are often present in UTIs, their presence alone is not indicative of a symptomatic infection.

The presence of bacteriuria does not guarantee negative outcomes for a patient. In fact, the paradigm of the sterility of the bladder environment has changed considerably over recent years. At least for females, the presence of female urinary microbiota (FUM) is believed to occur naturally and has been documented using sensitive bacterial DNA screening tests on asymptomatic females (Brubaker & Wolfe, 2016). Beneficial microbes, such as vaginal strains of Lactobacillus, can inhibit the growth of uropathogenic bacteria, including E. coli (Aroutcheva et al., 2001; Brubaker & Wolfe, 2016). Over-prescribing antibiotics, especially in cases of asymptomatic bacteriuria, can lead to both an eradication of beneficial bacterial flora and an emergence of antibiotic-resistant bacteria. Prescribing antibiotics as a prophylactic measure or in the instance of asymptomatic bacteriuria is detrimental because it is of limited value and can also increase incidences of drug-resistance. A study in 2002 by Harding and colleagues shows that antibiotic treatment in diabetic women with asymptomatic bacteriuria did not result in a decrease of future symptomatic UTIs as compared to the control group; in fact, the experimental group had higher rates of adverse antimicrobial reactions (Harding, Zhanel, Nicolle, & Cheang, 2002). Even though the evidence-based guidelines by various societies, such as the EAU (Bonkat et al., 2018) and SHEA (SHEA, 2015), do not recommend performing urine testing or treatment for asymptomatic bacteriuria, inappropriate treatment is still occurring; in fact, one study by Cope and colleagues shows that 32% of catheter-associated cases of asymptomatic bacteriuria and asymptomatic UTI received inappropriate treatment (Cope et al., 2009). The Antimicrobial Resistance Epidemiological Survey on Cystitis (ARESC) shows that up to 10.3% of E. coli in UTIs are "resistant to at least three different classes of antimicrobial agents," with ampicillin having the highest degree of resistance (48.3%). This is a large study of 4,264 women from ten different countries to show that antibiotic-resistance is of international importance (Schito et al., 2009).

Analytical Validity
Urinalysis to detect nitrite and leukocyte esterase to indicate the presence of bacteria is an accepted laboratory practice. One report, though, has shown that the use of nitrite has "a sensitivity of 3%, a specificity of 97%, and a negative predictive value of 55% (Cooper, Raeburn, Hamilton-Miller, & Brumfitt, 1992)." A 2004 meta-analysis study (Devillé et al., 2004) asserts that the "sensitivities of the combination of both tests vary between 68% and 88% in different patient groups, but positive test results have to be confirmed." They did note that the accuracy of the leukocyte esterase testing was higher in urology patients with a diagnostic odds ratio (DOR) of 276 as compared to the accuracy of nitrites (for example, in elderly patients, DOR = 108).

Urine culture is considered a "gold standard" for detecting the presence of bacteria in urine (Graham & Galloway, 2001; Schmiemann, Kniehl, Gebhardt, Matejczyk, & Hummers-Pradier, 2010). That being said, "the interpretation of culture results can be considered as more of an art than a science. A urine culture result depends on so many variables, such as appropriate collection, transport, and the limits of the methods of detection. The reliability of single positive urine culture in diagnosing UTI is only 80%, rising to 90% if a repeat culture shows identical results (Graham & Galloway, 2001)." This is using the definition of bacteriuria as being 105 bacteria/ml of urine.

Clinical Validity and Utility
A study in 2010 ((Bruyere, d'Arcier, Boutin, & Haillot, 2010) using 353 patients undergoing prostate biopsy shows that the routine use of obtaining a pre-operative urine culture is not clinically relevant to positive outcomes. "Of the 353 men, 12 had a pre-biopsy-positive bacterial culture and underwent prostate biopsy without any infections complication. Fifteen patients with a negative pre-biopsy culture developed a post-biopsy-positive bacterial culture, but remained asymptomatic without any treatment. Only four men from the group without pre-biopsy bacteriuria developed an infectious complication, requiring 3 weeks of antibiotic therapy." Both experimental and control groups had similar rates of complication, suggesting "that routine urine bacterial culture before prostate biopsy is not useful when antibiotic prophylaxis and enema are performed."

The method of obtaining the urine sample for culture testing is important. This is especially true for children. A 2017 study of 4,808 acutely ill children demonstrated that there was modest agreement between the results obtained if the test was conducted by a research laboratory versus a health service laboratory; however, the method of obtaining the urine sample did have significance. The calculated areas under the receiver-operator curve (AUC) for UTI ranged from 0.75-0.86 if the sample was obtained using a clean-catch method versus AUC values of 0.65-0.79 if the sample was obtained using "nappy pad samples." The authors' conclusions were that urine cultures did not necessarily have to be sent to a research lab for testing, but that "primary care clinicians should try to obtain clean catch samples, even in very young children (Birnie et al.)." A smaller study of 83 infants compared the use of urine obtained either via bladder catheterization or suprapubic aspiration (SPA) (Eliacik et al., 2016). All 83 infants had previously tested positive using urine culture samples obtained via bladder catheterization. Then they had samples removed by SPA. The SPA samples were used in both urinalysis and urine culture testing, and "only 24 (28.9%) and 20 (24%) yielded positive urine culture and abnormal urinalysis data, respectively." This indicates a 71.1% false-positive result rate if the urine sample is obtained using bladder catheterization. "In infants younger than 12 months, SPA is the best method to avoid bacterial contamination, showing better results than transurethral catheterization (Eliacik et al., 2016)."

Another study (Ducharme, Neilson, & Ginn, 2007) researched the use of either urine cultures and/or reagent test strips for use in diagnosing UTIs in elderly patients. The study consisted of 100 elderly patients, with one group having no symptoms and non-infectious complaints, and a second group "presenting with acute confusion, weakness or fever but no apparent urinary symptoms." Their results show that "of the 33 positive cultures, 10 had negative reagent strips. Thirteen of the 14 positive nitrite tests were culture positive for a specificity of 92.8% and a sensitivity of 36.1%. Positive cultures did not infer a diagnosis of UTI. Of the 67 positive reagent strips, 41 (61.2%) were associated with negative cultures." They conclude that, "in the elderly, reagent testing is an unreliable method of identifying patients with positive blood cultures. Moreover, positive urine culture rates are only slightly higher in patients with vague symptoms attributable to UTI than they are in (asymptomatic) patients treated for non-urologic problems, which suggests that many positive cultures in elderly patients with non-focal systemic symptoms are false-positive tests reflecting asymptomatic bacteriuria and not UTIs (Ducharme et al., 2007)."

A study by Price and colleagues (Price et al., 2016) shows that using an enhanced quantitative urine culture (EQUC) increased the detection of microorganisms in UTIs. This study consisted of 150 female patients using an initial UTI symptom assessment questionnaire to divide them into symptomatic and asymptomatic groups. Both sets underwent culture testing using both conventional urine culture testing and an EQUC method. "Compared to expanded-spectrum EQUC, standard urine culture missed 67% of uropathogens overall and 50% in participants with severe urinary symptoms. Thirty-six percent of participants with missed uropathogens reported no symptom resolution after treatment by standard urine culture results." Their protocol resulted in an "84% uropathogen detection relative to 33% detection by standard urine culture."

Regulatory Status
Since 1978, the FDA has approved several urine culture kits and devices (FDA, 2018). Additionally, many labs have developed specific urine culture tests that they must validate and perform in-house. These laboratory-developed tests (LDTs) are regulated by the Centers for Medicare & Medicaid Services (CMS) as high-complexity tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). As an LDT, the U.S. Food and Drug Administration has not approved or cleared this test; however, FDA clearance or approval is not currently required for clinical use.

Policy  

  1. In pregnant women, urinalysis and urine culture testing (with isolate identification and antibiotic susceptibilities if applicable) for any urinary tract infection, asymptomatic or symptomatic, including suspected cystitis, pyelonephritis, and asymptomatic bacteriuria, is considered MEDICALLY NECESSARY.  
  2. For asymptomatic patients prior to undergoing urological interventions breaching the mucosa, urinalysis and urine culture testing (with isolate identification and antibiotic susceptibilities if applicable) is considered MEDICALLY NECESSARY.  
  3. For asymptomatic urinary tract infection or asymptomatic bacteriuria in all other instances, urine culture testing (with isolate identification and antibiotic susceptibilities if applicable) is considered NOT MEDICALLY NECESSARY.  
  4. For patients exhibiting at least one sign or symptom of possible UTI or bacteriuria* (See Note 1 below), urinalysis and urine culture testing (with isolate identification and antibiotic susceptibilities if applicable) is considered MEDICALLY NECESSARY.   
  5. To assess pyelonephritis, urinalysis and urine culture testing (with isolate identification and antibiotic susceptibilities if applicable) is considered MEDICALLY NECESSARY.  
  6. Urinalysis and urine culture testing (with isolate identification and antibiotic susceptibilities if applicable) is considered INVESTIGATIONAL in the following situations:
    • As part of initial screening for asymptomatic prostatitis; OR
    • As part of assessment or prognosis of prostate biopsy.

*NOTE 1:  Signs and symptoms of UTI/bacteriuria include (CDC, 2018) (CDC link: https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/uti.html)   

  • Fever
  • Urgency to urinate
  • Feeling the need to urinate despite having an empty bladder
  • Increased frequency of urination
  • Dysuria
  • Suprapubic tenderness
  • Pyuria
  • Hematuria
  • Cloudy urine
  • Lower back and side (flank) pain
  • Nausea
  • Vomiting
  • Chills
  • Night sweats
  • Pelvic pressure
  • Change in urine smell
  • Abnormal urinalysis findings

Rationale 

2015 2017 Choosing Wisely (AAP, 2016; AMDA, 2017; SHEA, 2015)

Choosing Wisely, an initiative by the ABIM Foundation, consists of a number of national organizations representing medical specialists who write recommendations within their respective fields to help choose care based on scientific evidence and to help reduce testing redundancy.

2017 AMDA-The Society for Post-Acute and Long-Term Care Medicine (AMDA, 2017)

In 2017, the AMDA updated its earlier 2013 Choosing Wisely guideline concerning the use of urine cultures. Due to the high prevalence (up to 50%) of chronic asymptomatic bacteriuria in a long-term care setting, it states, "Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract." Since the urine culture would have a high likelihood of yielding a positive result in an otherwise asymptomatic case, this "contributes to the over-use of antibiotic therapy in this setting, leading to an increased risk of diarrhea or other adverse drug events, resistant organisms and infection due to Clostridium difficile." It also notes that "the finding of asymptomatic bacteriuria may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the more timely detection of the patient’s more serious underlying problem."  

2016 American Academy of Pediatrics (AAP, 2016)

The AAP updated its Choosing Wisely recommendation in 2016: "Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteriuria. There is no evidence that surveillance urine cultures or treatment of asymptomatic bacteriuria is beneficial. Surveillance cultures are costly and produce both false-positive and false-negative results. Treatment of asymptomatic bacteriuria is harmful and increases exposure to antibiotics, which is a risk factor for subsequent infections with a resistant organism. This also results in the overall use of antibiotics in the community and may lead to unnecessary imaging."  

2015 Society for Healthcare Epidemiology of America (SHEA, 2015)

The SHEA recommendation in Choosing Wisely is more encompassing: "Don’t perform urinalysis, urine culture, blood culture or C. difficile testing unless patients have signs or symptoms of infection. Tests can be falsely positive, leading to overdiagnosis and overtreatment. Although important for diagnosing disease when used in patients with appropriate signs or symptoms, these tests often are positive when an infection is not present. For example, in the absence of signs or symptoms, a positive blood culture may represent contamination, a positive urine culture could represent asymptomatic bacteriuria, and a positive test for C. difficile could reflect colonization. There are no perfect tests for these or most infections. If these tests are used in patients with low likelihood of infection, they will result in more false positive tests than true positive results, which will lead to treating patients without infection and exposing them to risks of antibiotics without benefits of treating an infection."  

2018 European Association of Urology (EAU) (Bonkat et al., 2018)

The EAU in 2018 released an update to its extensive guidelines concerning urological infections. With respect to asymptomatic bacteriuria, it states (all with a "Strong" strength of rating), "Do not screen or treat asymptomatic bacteriuria in the following conditions:  

  • Women without risk factors;
  • Patients with well-regulated diabetes mellitus;
  • Post-menopausal women;
  • Elderly institutionalised patients;
  • Patients with dysfunctional and/or reconstructed lower urinary tracts;
  • Patients with renal transplants;
  • Patients prior to arthroplasty surgeries;
  • Patients with recurrent urinary tract infections."

It does recommend with a "Strong" rating to "screen for and treat asymptomatic bacteriuria prior to urological procedures breaching the mucosa" and to "screen for and treat asymptomatic bacteriuria in pregnant women with standard short-course treatment." For the latter, however, it should be noted that it is a "Weak" strength of rating. It does recommend to "diagnose recurrent UTI by urine culture" with a "Strong" rating. Please note that recurrent UTI indicates that the occurrences are symptomatic. In general, it only weakly recommends to "use laboratory urine culture to detect bacteriuria in patients prior to undergoing urological interventions breaching the mucosa."

With respect to uncomplicated cystitis, it gives a "Strong" rating to only perform urine culture analysis "in the following situations:

  • Suspected acute pyelonephritis;
  • Symptoms that do not resolve or recur within four weeks after the completion of treatment;
  • Women who present with atypical symptoms;
  • Pregnant women."

The EAU gives a "Weak" recommendation to "use urine dipstick testing for diagnosis of acute uncomplicated cystitis."

In cases of uncomplicated pyelonephritis, the EAU recommends with a "Strong" rating to "perform urinalysis (e.g., using a dipstick method), including the assessment of white and red blood cells and nitrite, for routine diagnosis" and to "perform urine culture and antimicrobial susceptibility testing in patients with pyelonephritis."

The EAU defines complicated UTI (cUTI) as occurring "in an individual in whom factors related to the host (e.g., underlying diabetes or immunosuppression) or specific anatomical or functional abnormalities related to the urinary tract (e.g., obstruction, incomplete voiding due to detrusor muscle dysfunction) are believed to result in an infection that will be more difficult to eradicate than an uncomplicated infection." Other factors associated with cUTIs include vesicoureteral reflux, recent history of instrumentation, UTI in males, pregnancy, and health care-associated infections. "Laboratory urine culture is the recommended method to determine the presence or absence of clinically significant bacteriuria in patients suspected of having a cUTI."

For catheter-associated UTIs (CAUTI), the EAU recommends with "Strong" ratings to "not carry out routine urine culture in asymptomatic catheterised patients," to "not use pyuria as an indicator for catheter-associated UTI," and to "not use the presence or absence of odorous or  cloudy urine alone to differentiate catheter-associated asymptomatic bacteriuria from catheter-associated UTI.”

In cases of urethritis and urosepsis, the EAU states that “in all patients with urethritis, and when sexual transmission is suspected, the aim should be to identify the pathogenic organisms…. Laboratories should use validated nucleic acid amplification tests (NAATs) to detect chlamydia and gonorrhea, in first-void urine samples, as they are better than any of the other tests available for the diagnosis of chlamydial and gonococcal infections. N. gonorrhoeae and chlamydia cultures are mainly to evaluate treatment failures and monitor developing resistance to current treatment.” With a "Strong" rating, it recommends:

  • “Perform a gram stain of urethral discharge or a urethral smear to preliminarily diagnose pyogenic urethritis.”
  • “Perform a validated nucleic acid amplification test on a mid-stream urine sample or urethral smear to diagnose chlamydial and gonococcal infections.”
  • “Use a pathogen-directed treatment based on local resistance data.”

For the diagnosis and disease management of bacterial prostatitis (CBP), the EAU recommends with a "Strong" rating to “perform the Meares and Stamey 2- or 4-glass test in patients with CBP.” It only gives a "Weak" rating in the use of digital rectal examination, the urine dipstick test, and blood culture with a total blood count. It also gives a "Weak" rating to its recommendation to “not routinely perform microbiological analysis of the ejaculate alone to diagnosis CBP”; however, it gives a "Strong" recommendation to “treat acute bacterial prostatitis according to the recommendations for complicated UTI” where it recommends a laboratory urine culture. However, with respect to prostate biopsy, the EAU states that “urine culture prior to prostate biopsy has an uncertain predictive value.”

The EAU’s recommendation in cases of suspected acute infective epididymitis (with a "Strong" rating) is “to obtain a mid-stream urine and a first-voided urine for pathogen identification by culture and nucleic acid amplification test.” It should be noted that, if the acute scrotal pain and/or swelling is due to suspected torsion, then a urine culture is not necessary. Instead, in that case, “urgent surgical exploration” is recommended.

2016 World Health Organization (WHO, 2016)

The WHO recommendations on antenatal care for a positive pregnancy experience in 2016 do include a recommendation to test for asymptomatic bacteriuria (ASB) in pregnant women. “Midstream urine culture is the recommended method for diagnosing asymptomatic bacteriuria (ASB) in pregnancy. In settings where urine culture is not available, the on-site midstream urine Gram-staining is recommended over the use of dipstick tests as the method for diagnosing ASB in pregnancy." It does make note of the amount of time a urine culture takes (up to 7 days) but states that it is "the gold standard." The concern of ASB in pregnancy is because "ASB is associated with an increased risk of preterm birth."

2014 Canadian Paediatric Society (CPS) (Robinson et al., 2017) 

In 2014, the CPS issued its position statement, titled Urinary tract infection in infants and children: Diagnosis and management and reaffirmed its statement in 2017. Its recommendations are for children >2 months old. It recommends that "infants from 2 to 36 months of age with a fever of >39◦C and no other source for fever on history or physical examination…should have urine collected for urinalysis. Unless this test is completely normal, they should then have urine collected by catheter or suprapubic aspirate [SPA] sent for culture." If the child has been toilet-trained, then the urine sample can be collected midstream in lieu of the catheter. "Children with possible UTI who require antibiotic treatment immediately for other indications, such as suspected bacteremia, should have urine collected for urinalysis, microscopy, and culture." Again, this sample should be obtained via either catheterization or SPA, unless the child has been toilet-trained. It also states that "urine collection must occur before starting antibiotics because a single dose of an effective antibiotic rapidly sterilizes the urine."  

2011 American Academy of Pediatrics (AAP) (Roberts, 2011)

The AAP issued guidelines for UTIs in children 2 to 24 months of age in 2011. With an "A" grade for evidence quality and a strong recommendation, it issued its Action Statement 1: "If a clinician decides that a febrile infant with no apparent source for the fever requires antimicrobial therapy to be administered because of ill appearance or another pressing reason, the clinician should ensure that a urine specimen is obtained for both culture and urinalysis before an antimicrobial agent is administered; the specimen needs to be obtained through catheterization or SPA, because the diagnosis of UTI cannot be established reliably through culture of urine collected in a bag." For instances where the clinician believes that the febrile child does not warrant immediate antimicrobial therapy, the AAP in Action Statement 2 (strong recommendation; "A" grade of evidence) states the following: (Action Statement 2a) "If the clinician determines the febrile infant to have a low likelihood of UTI [in table below]…then the clinical follow-up monitoring without testing is sufficient." In Action Statement 2b, the AAP states: "If the clinician determines that the febrile infant is not in a low-risk group [in table below], then there are 2 choices. Option 1 is to obtain a urine specimen through catheterization or SPA for culture and urinalysis. Option 2 is to obtain a urine specimen through the most convenient means and to perform a urinalysis. If the urinalysis results suggest a UTI (positive leukocyte esterase test results or nitrite test or microscopic analysis results positive for leukocytes or bacteria), then a urine specimen should be obtained through catheterization or SPA and cultures; if urinalysis of fresh (<1 hour since void) urine yields negative leukocyte esterase and nitrite test results, then it is reasonable to monitor the clinical course without initiating anti-microbial therapy, recognizing that negative urinalysis results do not rule out a UTI with certainty."   

2009 Infectious Diseases Society of America (IDSA) (Hooton et al., 2010) & 2010 IDSA/European Society for Microbiology and Infectious Diseases (ESMID) (Gupta et al., 2011)

In 2009, IDSA issued its guidelines concerning the diagnosis, prevention, and management of asymptomatic and symptomatic CAUTIs, as well as catheter-associated asymptomatic bacteriuria (CAASB). It lists the symptoms of a CAUTI to "include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort; and in those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness." It also recommends that pyuria not be considered diagnostic of CA-bacteriuria or CAUTI; however, a level III recommendation does state that "the absence of pyuria in a symptomatic patient suggests a diagnosis other than [CAUTI]." Also as a level III recommendation, "in the catheterized patient, the presence or absence of odorous or cloudy urine alone should not be used to differentiate [CAASB] from [CAUTI] or as an indication for urine culture or antimicrobial therapy." Recommendation 45 (level III) states that "a urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed [CAUTI], because of the wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance"; moreover, if the catheter has been in place for more  than 2 weeks since the symptoms of a CAUTI began, a new catheter should be inserted prior to obtaining a urine sample for culture (Recommendation 46 part I; level II recommendation). It does make note that the incidence rate of bacteriuria in patients does increase with the length of time of catheterization, as well as how often urine cultures are performed on the patient (Hooton et al., 2010).   

In 2010, the IDSA and ESMID issued joint guidelines concerning acute uncomplicated cystitis and pyelonephritis in women. With a level III recommendation, in Recommendation 8, "in patients suspected of having pyelonephritis, a urine culture and susceptibility test should always be performed, and initial empirical therapy should be tailored appropriately on the basis of the infecting uropathogen (Gupta et al., 2011)."

2011 Canadian Urological Association (CUA) (Dason, Dason, & Kapoor, 2011) 

The CUA Guidelines for the diagnosis and management of recurrent urinary tract infection in women contain an algorithm for a "female without a prior history of structural or functional abnormalities of the urinary tract presenting with 3 or more UTIs in 12 months" that require a urine culture during a time when the patient is symptomatic followed by a urine culture two weeks after initiating treatment with sensitivity-adjusted antibiotics (Level 4 evidence, Grade C recommendation [Recommendation 2c]). In doing so, this "may aid in confirming the diagnosis of UTI, as well as guiding further specialist evaluation and management." For recurrent uncomplicated UTI, "culture and sensitivity analysis should be performed at least once while the patient is symptomatic…. A midstream urine bacterial count of 1 X 105 CFU/L should be considered a positive culture while the patient is symptomatic." For patients who choose an option of "self-start antibiotic" therapy, "it is not necessary to culture the urine after UTI self-diagnosis, since there is an 86% to 92% concordance between self-diagnosis and urine culture in an appropriately selected patient population. Patients are advised to contact a health care provider if symptoms do not resolve within 48 hours for treatment based on culture and sensitivity." 

American Urological Association (AUA) (Averch et al., 2014; Wolf et al., 2012) 

In the updated 2012 AUA guidelines Urologic Surgery Antimicrobial Prophylaxis, the AUA gives two options for patients post-procedure requiring catheterization. "In the absence of pre-existing bacterial colonization, there is no evidence that prophylaxis should extend beyond 24 hours following a procedure. In cases where prolonged catheterization follows the procedure (e.g., radical prostatectomy), antimicrobial therapy at the time of catheter removal may be therapeutic rather than prophylactic, since colonization has likely occurred. One option is to culture the urine 24 to 48 hours prior to intended catheter removal, and administer culture-directed therapy. This is not practical in many cases of catheterization for only 48 to 72 hours, and may be misleading. The other option is to administer antimicrobial treatment empirically. The Panel does not make a recommendation as to which option is preferable (Wolf et al., 2012)."  

The AUA issued a white paper in 2014 concerning CAUTIs. In the white paper, it refers to the use of the National Surgical Quality Improvement Program (NSQIP) definition of UTIs, which does reference the use of urine culture. It should be noted, however, that this definition requires at least a minimum of one of the following symptoms: fever (>38◦C), urgency, frequency, dysuria, or suprapubic tenderness. It, too, refers to the 2009 IDSA guidelines concerning CAUTIs, as well as those of the EAU. TIt states that there are "no consistent guidelines are available on how to obtain urine for culture from chronically catheterized patients, or what constitutes true urinary tract infection versus asymptomatic bacteriuria." It makes note of a study concerning the possible cost-effectiveness of the use of dipsticks to screen asymptomatic ICU patients for CAUTIs. It concludes, "however, as previously discussed, screening of asymptomatic patients may not be warranted, and treatment is usually not recommended in these cases (Averch et al., 2014)." 

References 

  1. AAP. (2016, 07/13/2016). Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteriuria. Ten Things Physicians and Patients Should Question. Retrieved from http://www.choosingwisely.org/clinician-lists/american-academy-pediatrics-surveillance-cultures-to-screen-and-treat-asymptomatic-bacteruria/   
  2. AMDA. (2017). Don't obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract. Five Things Physicians and Patients Should Question. Retrieved from http://www.choosingwisely.org/clinician-lists/amda-urine-cultures/
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  18. Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., . . . Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis, 52(5), e103-120. doi:10.1093/cid/ciq257
  19. Harding, G. K., Zhanel, G. G., Nicolle, L. E., & Cheang, M. (2002). Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med, 347(20), 1576-1583. doi:10.1056/NEJMoa021042
  20. Hooton, T. M., Bradley, S. F., Cardenas, D. D., Colgan, R., Geerlings, S. E., Rice, J. C., . . . Nicolle, L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis, 50(5), 625-663.
  21. Hooton, T. M., & Gupta, K. (2018, 04/20/2018). Acute complicated urinary tract infection (including pyelonephritis) in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/acute-complicated-urinary-tract-infection-including-pyelonephritis-in-adults
  22. Meyrier, A. (2017, 06/01/2017). Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/sampling-and-evaluation-of-voided-urine-in-the-diagnosis-of-urinary-tract-infection-in-adults
  23. Price, T. K., Dune, T., Hilt, E. E., Thomas-White, K. J., Kliethermes, S., Brincat, C., . . . Schreckenberger, P. C. (2016). The Clinical Urine Culture: Enhanced Techniques Improve Detection of Clinically Relevant Microorganisms. Journal of Clinical Microbiology, 54(5), 1216-1222. doi:10.1128/JCM.00044-16
  24. Roberts, K. B. (2011). Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 128(3), 595-610. doi:10.1542/peds.2011-1330
  25. Robinson, J. L., Finlay, J. C., Lang, M. E., Bortolussi, R., CPS, CPC, & IDIC. (2017, 03/20/2018). Urinary tract infections in infants and children: Diagnosis and management. Position Statements and Practice Points. Retrieved from https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children
  26. Schito, G. C., Naber Kg Fau - Botto, H., Botto H Fau - Palou, J., Palou J Fau - Mazzei, T., Mazzei T Fau - Gualco, L., Gualco L Fau - Marchese, A., & Marchese, A. (2009). The ARESC study: an international survey on the antimicrobial resistance of pathogens involved in uncomplicated urinary tract infections. Int J Antimicrob Agents, 34(5), 407-413.
  27. Schmiemann, G., Kniehl, E., Gebhardt, K., Matejczyk, M. M., & Hummers-Pradier, E. (2010). The Diagnosis of Urinary Tract Infection: A Systematic Review. Deutsches Ärzteblatt International, 107(21), 361-367. doi:10.3238/arztebl.2010.0361
  28. SHEA. (2015, 10/01/2015). Don't perform urinalysis, urine culture, blood culture or C. difficile testing unless patients have signs or symptoms of infection. Five Things Physicians and Patients Should Question. Retrieved from http://www.choosingwisely.org/clinician-lists/shea-urinalysis-urine-culture-blood-culture-or-c-difficile-testing/
  29. WHO. (2016). WHO Guidelines Approved by the Guidelines Review Committee. In WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization
  30. Copyright (c) World Health Organization 2016.
  31. Wolf, J. S. J., Bennett, C. J., Dmochowski, R. R., Hollenbeck, B. K., Pearle, M. S., Schaeffer, A. J., & Pace, K. T. (2012, 07/29/2016). Urologic Surgery Antimicrobial Prophylaxis. Best Practices Statements. Retrieved from http://www.auanet.org/guidelines/antimicrobial-prophylaxis-(2008-reviewed-and-validity-confirmed-2011-amended-2012)

Coding Section

Code

Number 

Description 

CPT 

81000 

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 

 

81001

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy 

 

81002 

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 

 

81003 

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, anynumber of these constituents; automated, without microscopy 

 

81005

Urinalysis; qualitative or semiquantitative, except immunoassays

 

81007

Urinalysis; bacteriuria screen, except by culture or dipstick

 

81015

Urinalysis; microscopic only

 

81020

Urinalysis; 2 or 3 glass test

 

87077

Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate

 

87086

Culture, bacterial; quantitative colony count, urine

 

87088

Culture, bacterial; with isolation and presumptive identification of each isolate, urine

 

87140

Culture, typing; immunofluorescent method, each antiserum

 

87149

Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed

 

87181

Susceptibility studies, antimicrobial agent; agar dilution method, per agent (e.g., antibiotic gradient strip)

 

87147 

Culture, typing; immunologic method, other than immunofluorescence (e.g., agglutination grouping), per antiserum  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2018 Forward     

09/04/2018 

This Policy has an effective date of 12/01/2018.

08/14/2018

New Policy


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