1439. Reducing the Number of Urine Cultures Performed Through Stringent Urinalysis Reflex Criteria

BACKGROUND: Almost half of urine cultures (UCs) obtained are in asymptomatic patients, which may lead to misdiagnosis of urinary tract infection (UTI) and unnecessary treatment. To decrease misdiagnosis of UTI, changes were made to the order entry and urine culture process at our institution in April 2018. This included removal of a standalone UC from the electronic order entry system and development of a more stringent criterian for urinalysis with reflex culture (UAC). We evaluated the impact of these ordering changes on the total number of UCs performed. METHODS: This was a pre-post retrospective study comparing the hospital UAC rate per 1,000 patient-days and ED UAC rate per 1,000 visits in the pre-intervention period from April 2017 to March 2018 to the intervention period from May 2018 to March 2019 in a 319-bed teaching hospital in northwest Ohio. In April 2018, urine microscopy and UAC were the only available options. Furthermore, UC would only be performed if the following criteria were met: 10 white blood cells (WBC)/HFP. Standalone UC was available for the following patients who were excluded: immunosuppressed patients, pregnant women and patients undergoing invasive urologic procedures. These changes were accompanied by provider education, and providers were given the option to override UAC rules by calling the microbiology lab within 24 hours to request UC. RESULTS: After incorporating these changes, we observed an increase in the use of UAC compared with UC-only in both the ED (80% pre-vs. 94% post-implementation) and inpatient setting (59% pre-vs. 92% post-implementation). This was accompanied by a reduction in the overall UCs performed in both the ED (49.17 per 1,000 visits to 23.53 per 1,000 visits [P < 0.001]) and inpatient units (23.31 per 1,000 patient-days to 9.31 per 1,000 patient-days [P < 0.001]). Chart review of cases where providers overrode UAC criteria and requested UC have demonstrated no false negatives to date; cultures either had no growth or were consistent with contamination by polymicrobial urogenital flora. CONCLUSION: Restricted access to standalone UC, implementation of UAC with more stringent criteria and provider education reduced the number of urine cultures performed without sacrificing sensitivity for detecting UTI and potential antimicrobial use. DISCLOSURES: All authors: No reported disclosures.