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Diagnosis of urinary tract infections: need for a reflective rather than reflexive approach

We read great interest the study by Munigala et al 1 on the impact of changing urine testing orderables on the number and positivity of urine cultures. With the increased attention to catheter-associated urinary tract infection (CAUTI), the vast majority of hospitals in the United States have steered their attention to “ stewardship of culturing ” to reduce the detection of asymptomatic catheter-associated bacteriuria. In this retrospec-tive study, the authors evaluate changing urine culture reflex testing in order sets and engaging clinicians regarding the change. Prior to the intervention, a urinalysis would be reflexed to culture if it included any protein, blood, nitrite, or leukocyte-esterase positive results. With the intervention, the urinalysis reflexed to culture only if it was positive for either nitrite or leukocyte esterase. A 45% reduction in urine cultures performed was observed after implementation, although catheter-associated bacteriuria and CAUTI rates did not significantly change. urinalysis parameters of or both elements not typically associated with reflexing to for reflex culture in the in catheter-associated bacteriuria