No CrossRef data available.
Article contents
Clinical factors and diagnoses associated with inappropriate urine culture ordering in primary care
Published online by Cambridge University Press: 21 October 2025
Abstract
Objective:
Evaluate the prevalence and risk factors for inappropriately ordered urine cultures in primary care.
Design:
Cross-sectional study using chart reviews.
Setting:
Two primary care, safety-net clinics in Houston, Texas.
Patients:
Non-pregnant adults without a urinary catheter who had a urine culture and a primary care visit between 11/2018 and 3/2020.
Methods:
We classified patients lacking physician documentation of the following symptoms as having an inappropriately ordered urine culture: dysuria, frequency, urgency, hematuria, fever, chills, costovertebral angle tenderness, nephrolithiasis, and pain (suprapubic, pelvic, or flank). We extracted patient demographics, visit-related diagnostic codes, past medical history, and urine culture results. Diagnostic codes were grouped based on body system, visit type (e.g. routine visit), or sign or symptom clusters. We evaluated the relationship between these factors and inappropriately ordered cultures using generalized estimating equations logistic regression.
Results:
We included 807 patients who had 870 visits. Most patients were Hispanic (66.3%) or African American/Black (24.8%) females (76.1%) with a median age of 50 years. Among 870 cultures, 210 (24%) were ordered inappropriately. We found having an abnormal urinalysis or urine characteristic (adjusted odds ratio (aOR): 13.66), acute low back pain (aOR: 4.88), a cardiovascular-related (aOR: 1.68) or gynecological/family planning visit (aOR: 10.84), being evaluated at the non-teaching clinic (aOR: 6.03), or having a routine health visit (aOR: 1.81) within the non-teaching clinic (interaction aOR: 4.27) were significantly associated with inappropriate urine cultures.
Conclusions:
Our study revealed factors associated with inappropriately ordered urine cultures that may be unique to ambulatory settings and can help design outpatient diagnostic stewardship interventions.
Information
- Type
- Original Article
- Information
- Copyright
- © The Author(s), 2025. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America
Footnotes
Statement on previous publication: An abstract of this work was previously presented at the Society for Healthcare Epidemiology of America annual meeting in April 2023, which was subsequently published in Antimicrobial Stewardship and Healthcare Epidemiology as a supplement.
References
Yang, X, Chen, H, Zheng, Y, Qu, S, Wang, H, Yi, F. Disease burden and long-term trends of urinary tract infections: a worldwide report. Front Public Health 2022;10:1–13. Electronic.Google ScholarPubMed
Gupta, K, Hooton, TM, Naber, KG, et al. 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 2011;52:e103–120.10.1093/cid/ciq257CrossRefGoogle Scholar
Garcia, R, Spitzer, ED. Promoting appropriate urine culture management to improve health care outcomes and the accuracy of catheter-associated urinary tract infections. Am J Infect Control 2017;45:1143–1153.10.1016/j.ajic.2017.03.006CrossRefGoogle ScholarPubMed
Flokas, ME, Andreatos, N, Alevizakos, M, Kalbasi, A, Onur, P, Mylonakis, E. Inappropriate management of asymptomatic patients with positive urine cultures: a systematic review and meta-analysis. Open Forum Infect Dis 2017;4:ofx207.10.1093/ofid/ofx207CrossRefGoogle ScholarPubMed
Valentine-King, M, Van, J, Hines-Munson, C, et al. Identification of novel factors associated with inappropriate treatment of asymptomatic bacteriuria in acute and long-term Care. Am J Infect Control 2022;50:1226–1233.10.1016/j.ajic.2022.02.010CrossRefGoogle ScholarPubMed
Nicolle, LE, Gupta, K, Bradley, SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the infectious diseases society of America. Clin Infect Dis 2019;68:1611–1615.10.1093/cid/ciz021CrossRefGoogle ScholarPubMed
Nicolle, LE, Bradley, S, Colgan, R, Rice, JC, Schaeffer, A, Hooton, TM. Infectious diseases society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–654.10.1086/427507CrossRefGoogle Scholar
Owens, DK, Davidson, KW, Krist, AH, et al. Screening for asymptomatic bacteriuria in adults: us preventive services task force recommendation statement. JAMA 2019;322:1188–1194.Google ScholarPubMed
Drekonja, DM, Grigoryan, L, Lichtenberger, P, et al. Teamwork and safety climate affect antimicrobial stewardship for asymptomatic bacteriuria. Infect Control Hosp Epidemiol 2019;40:963–967.10.1017/ice.2019.176CrossRefGoogle ScholarPubMed
Petty, LA, Vaughn, VM, Flanders, SA, et al. Risk Factors and Outcomes Associated With Treatment of Asymptomatic Bacteriuria in Hospitalized Patients. JAMA Intern Med 2019;179:1519–1527.10.1001/jamainternmed.2019.2871CrossRefGoogle ScholarPubMed
Hartley, S, Valley, S, Kuhn, L, et al. Overtreatment of asymptomatic bacteriuria: identifying targets for improvement. Infect Control Hosp Epidemiol 2015;36:470–473.10.1017/ice.2014.73CrossRefGoogle ScholarPubMed
Hartley, S, Valley, S, Kuhn, L, et al. Inappropriate testing for urinary tract infection in hospitalized patients: an opportunity for improvement. Infect Control Hosp Epidemiol 2013;34:1204–1207.10.1086/673449CrossRefGoogle ScholarPubMed
Leis, JA, Gold, WL, Daneman, N, Shojania, K, McGeer, A. Downstream impact of urine cultures ordered without indication at two acute care teaching hospitals. Infect Control Hosp Epidemiol 2013;34:1113–1114.10.1086/673151CrossRefGoogle ScholarPubMed
Drekonja, DM, Gnadt, C, Kuskowski, MA, Johnson, JR. Urine cultures among hospitalized veterans: casting too broad a net? Infect Control Hosp Epidemiol 2014;35:574–576.10.1086/675829CrossRefGoogle ScholarPubMed
Yin, P, Kiss, A, Leis, JA. Urinalysis orders among patients admitted to the general medicine service. JAMA Intern Med 2015;175:1711–1713.10.1001/jamainternmed.2015.4036CrossRefGoogle Scholar
Sloane, PD, Kistler, CE, Reed, D, Weber, DJ, Ward, K, Zimmerman, S. Urine culture testing in community nursing homes: gateway to antibiotic overprescribing. Infect Control Hosp Epidemiol 2017;38:524–531.10.1017/ice.2016.326CrossRefGoogle ScholarPubMed
Santo, L OT. National Ambulatory Medical Care Survey: 2018 National Summary Tables.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statisics;2018.Google Scholar
Cairns, CKK, Santo, L. National hospital ambulatory medical care survey: 2018 Emergency department summary tables.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statisics;2018.Google Scholar
McDermott, KW RM. Most Frequent Principal Diagnoses for Inpatient Stays in U.S. Hospitals, 2018. HCUP Statistical Brief #277. Rockville, MD2021.Google Scholar
Hansen, MA, Valentine-King, M, Zoorob, R, et al. Prevalence and predictors of urine culture contamination in primary care: a cross-sectional study. Int J Nurs Stud 2022;134:1–9.10.1016/j.ijnurstu.2022.104325CrossRefGoogle ScholarPubMed
Valentine-King, M, Hansen, MA, Zoorob, R, et al. Determining a urinary-specific antibiogram and risk factors of trimethoprim/sulfamethoxazole, ciprofloxacin and multidrug resistance among Enterobacterales in primary care. J Antimicrob Chemother 2024;79:559–563.10.1093/jac/dkae004CrossRefGoogle ScholarPubMed
Kolman, KB. Cystitis and pyelonephritis: diagnosis, treatment, and prevention. Prim Care 2019;46:191–202.10.1016/j.pop.2019.01.001CrossRefGoogle ScholarPubMed
Pearle, MS, Goldfarb, DS, Assimos, DG, et al. Medical management of kidney stones: AUA guideline. J Urol 2014;192:316–324.10.1016/j.juro.2014.05.006CrossRefGoogle ScholarPubMed
Szklo, M, Nieto, FJ. Epidemiology: beyond the basics. 3rd ed. Burlington, Mass.: Jones & Bartlett Learning; 2014.Google Scholar
Knol, MJ, VanderWeele, TJ, Groenwold, RH, Klungel, OH, Rovers, MM, Grobbee, DE. Estimating measures of interaction on an additive scale for preventive exposures. Eur J Epidemiol 2011;26:433–438.10.1007/s10654-011-9554-9CrossRefGoogle Scholar
Knol, MJ, VanderWeele, TJ. Recommendations for presenting analyses of effect modification and interaction. Int J Epidemiol 2012;41:514–520.10.1093/ije/dyr218CrossRefGoogle ScholarPubMed
Højsgaard, S, Halekoh, U, Yan, J. The R package geepack for generalized estimating equations. J of Statistical Software 2005;15:1–11.Google Scholar
Fleming-Dutra, KE, Hersh, AL, Shapiro, DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA 2016;315:1864–1873.10.1001/jama.2016.4151CrossRefGoogle ScholarPubMed
Horstman, MJ, Spiegelman, A, Naik, AD, Trautner, BW. National patterns of urine testing during inpatient admission. Clin Infect Dis 2017;65:1199–1205.10.1093/cid/cix424CrossRefGoogle ScholarPubMed
Petty, LA, Vaughn, VM, Flanders, SA, et al. Assessment of testing and treatment of asymptomatic bacteriuria initiated in the emergency department. Open Forum Infect Dis 2020;7:ofaa537.10.1093/ofid/ofaa537CrossRefGoogle ScholarPubMed
Haq, K, Patel, DM. Urinalysis: interpretation and clinical correlations. Med Clin North Am 2023;107:659–679.10.1016/j.mcna.2023.03.002CrossRefGoogle ScholarPubMed
Tuddenham, S, Hamill, MM, Ghanem, KG. Diagnosis and treatment of sexually transmitted infections: a review. JAMA 2022;327:161–172.10.1001/jama.2021.23487CrossRefGoogle ScholarPubMed
Tomas, ME, Getman, D, Donskey, CJ, Hecker, MT. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol 2015;53:2686–2692.10.1128/JCM.00670-15CrossRefGoogle ScholarPubMed
Germanos, G, Light, P, Zoorob, R, et al. Validating use of electronic health data to identify patients with urinary tract infections in outpatient settings. Antibiotics 2020;9:1–8.10.3390/antibiotics9090536CrossRefGoogle ScholarPubMed
Young, EH, Strey, KA, Lee, GC, et al. National disparities in antibiotic prescribing by race, ethnicity, age group, and sex in United States ambulatory care visits, 2009 to 2016. Antibiotics 2023;12(1):1–9.Google Scholar
Valentine-King et al. supplementary material
Valentine-King et al. supplementary material
File
20.2 KB