2026 Southeastern Residency Conference

Authors: Cameron Howell, PharmD; Layla Marefat, PharmD 

Background: Asymptomatic bacteriuria (ASB) is the presence of bacteria [>100,000 colony forming units per milliliter (CFUs/mL)] in the urine without associated genitourinary symptoms.  Up to 60% of patients with ASB [and an additional 40% with asymptomatic pyuria and/or nitrituria (ASPN)] receive antibiotics when not indicated. Reflex urine culture algorithms are a tool used to decrease urine culture rates, which reduces unnecessary antibiotic use. Typically, the reflex criteria for these algorithms include urinalysis components, of which pyuria is the most reliable for predicting a clinically significant urinary tract infection (UTI). In 2018, reflex urine cultures were implemented at the Baptist Health System using a traditional cutoff of >5 white blood cells per high power field (WBC/HPF) for pyuria. A recent study found that <10 WBC/HPF has a similarly high negative predictive value for UTI than less stringent cutoffs. Thus, in July 2025, the definition for pyuria was refined to >10 WBC/HPF, leading to a threefold increase in overrides of the algorithm.  The aim of this study is to evaluate the impact of delivering education to providers on adherence to a urine culture guidance algorithm.
 
Methods: A retrospective chart review was conducted on adult patients at a community hospital who had a urine culture obtained from an override of established reflex criteria. The primary outcome was the percentage of inappropriate urine culture overrides. It was assessed for a pre-intervention phase from January 1, 2025, to April 30, 2025, and compared to the post-intervention phase from October 1, 2025, to January 31, 2026. Education was provided to hospitalists, emergency medicine providers, and intensivists.  Secondary outcomes included hospital length of stay (LOS), days of therapy (DOT) for patients with an inappropriate urine culture override that received antibiotics for UTI, and concordance of provider inputs for symptoms or "At Risk Population” on the urine culture order with patient chart documentation.

Results: 76 patients were evaluated in the pre-intervention group while 175 patients were evaluated in the post-intervention group. Most urine cultures obtained from overrides resulted in no growth or normal urogenital flora (76.3% vs. 62.3%, p = 0.030). Despite a reduction in inappropriate urine culture overrides compared to the pre-intervention phase, this difference was not statistically significant (57.8% vs. 48.0%, p = 0.15). Hospital LOS, DOT for those with inappropriate urine culture overrides, and concordance of provider inputs for symptoms on the order with patient chart documentation also were not significantly affected. The concordance of provider inputs for “At Risk Population” on the order with patient chart documentation was significantly higher in the post-intervention group (14.3% vs. 68.8%, p < 0.001).

Conclusions: Pharmacist education to providers was not effective in reducing inappropriate urine culture overrides. However, significant limitations were present, especially the difference in reflex criteria between groups. Nevertheless, most urine cultures did not yield clinically significant growth. Additional interventions must be pursued in addition to education to target higher adherence to a reflex urine culture algorithm.