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
Age
Chief Complaint
UTI Sx
UA Indicated
(Y – x / N)
Urine
Microscopy /
Culture (+ / -)
Antimicrobial
Therapy
Initiated
Antimicrobial
Therapy
Indicated
71
BL LE Cellulitiis
N
N
Negative
No
No
58
Chronic LE Cellulitis
/ Hypotension / AKI
N
Y
Negative
No
No
52
Myasthenia w/Cough
/ Sepsis
N
Y
Negative
No
No
45
Pulmonary Embolism
N
N
Negative
No
No
80
Abdominal Pain /
Dysuria
Y
Y
Positive
Yes
Yes
47
Nasopharyngeal CA
w/Bilateral Hand
Numbess
N
N
Negative
No
No
55
SVC Syndrome /
Incidental
leukocytosis
N
Y
Negative
No
No
85
Cough / Hypoxia
N
N
Negative
No
No
71
BL LE Cellulitis
N
N
Negative
No
No
35
RCC w/Fevers / AKI
Y
Y
Negative
No
No
66
Chest Pain (Hx CKD;
Cr at baseline)
N
N
Negative
No
No
77
Fever / AMS /
Dysuria
Y
Y
Positive
Yes
Yes
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. 1997
Sep;11(3):647-62.
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):1711-1713.