Turning a Patient Case into Patient Advocacy

Volume 38 Number 6 | December 2024

Sarah Bergbower, DCLS, MLS(ASCP)^CM, ASCLS Today Volunteer Contributor

A 32-year-old G4 P3003 presents for a regular obstetric visit at 28 weeks gestation. A point-of-care urine dipstick was performed on a freshly voided sample with the results of interest shown in Table 1. Results were not discussed with the patient at the appointment, but the nurse called the patient later that afternoon to ask, “What pharmacy should we send your antibiotics to?”

“Antibiotics? For what?” the patient replied.

“You have a UTI.”

“No, I don’t think so,” responded the patient, “I don’t have any symptoms.” The nurse emphasized that the UTI was diagnosed from the urine sample provided earlier that day. “And what exactly were the results?” the patient inquired.

“Your leukocyte esterase was positive.”

“How positive?”

“Small.”

“Small? That’s it? No nitrite or anything else?”

“No nitrite, a bit of blood, but really it’s the leukocyte esterase.”

“But I’m pregnant,” the patient adamantly declared, “leukocyte esterase is a common finding during pregnancy; it has more sources than just infection.”

“If you are choosing to refuse treatment, you’ll need to speak with the doctor.”

The physician and patient had developed a relationship of mutual respect, and the physician was willing to have a phone conversation with the patient. The patient learned from the physician the potential consequences of asymptomatic bacteriuria during pregnancy and common practice, but she still disagreed with the procedure of making a diagnosis from a dipstick without culture. The physician agreed to comply with the patient’s request, “We’ll get a culture, and if that culture comes back positive, you will get antibiotics.”

“Yes, I will.”

The patient came back the next day to provide a fresh, clean catch sample. Results are shown in Table 2. Of note, leukocyte esterase had increased to moderate, correlating with its microscopic evaluation of 11-18 white blood cells per high power field. Although few to moderate bacteria were seen in the microscopic urinalysis, no organisms were isolated by culture as of day four, and at day five, the culture concluded with only mixed flora skin contaminants. No UTI. The physician called the patient to discuss the results directly, including the decision not to prescribe antibiotics.

Although asymptomatic bacteriuria is a significant problem in the pregnant population, associated with preterm delivery, low birth weight, and maternal pyelonephritis, it is not of concern in the general population. Obstetric providers often screen for asymptomatic bacteriuria, whose prevalence in pregnancy is between 2-15 percent, during early gestation using a urine culture,¹ which is the gold standard diagnostic test. Following this initial culture, routine obstetric visits feature a point-of-care dipstick urinalysis, which is capable of screening for a variety of other conditions. However, the sensitivity and specificity of the dipstick for detecting urinary tract infections, including asymptomatic bacteriuria, is so low, some sources have declared it unsuitable as such a screen.² Therefore, when asymptomatic bacteriuria is suspected from the dipstick, a follow-up culture is recommended to guide diagnostics, and thus, antibiotic stewardship.

In the preceding case, had the patient not advocated for follow-up testing using gold standard diagnostics, she would have been misdiagnosed and prescribed unnecessary treatment, which may have further presented the potential for harm to both the developing fetus and mother.

The patient, by the way, was a trained medical laboratory scientist with generalist experience in urinalysis within the clinical laboratory. Very often, we become aware of issues within healthcare because either a loved one or we personally experience it, and as a result we desire to spread awareness and advocate for change. As medical laboratory professionals, we also tend to underestimate our knowledge and capacity to make an impact.

This case of patient advocacy inspired me to put sensitivity and specificity to work for other expecting mothers and their care providers; to develop and implement a diagnostic algorithm to guide urinalysis interpretation, diagnosis, and antibiotic stewardship of asymptomatic bacteriuria during pregnancy. This project was the basis of my Doctor of Clinical Laboratory Science (DCLS) research.

My research revealed that culture underutilization, which is capable of leading to diagnostic error, was a widespread problem, but implementation of the developed algorithm was associated with decreased rates of error. I have since created a recommendation for Choosing Wisely that is currently under consideration, which was formed by using the Evidence-Based Practice A-6 Cycle adapted from the Centers for Disease Control and Prevention (CDC) and described in the literature.³ I presented a poster on the recommendation’s development at the American Society for Clinical Pathology 2024 Annual Meeting. Additionally, my team and I have submitted our full study’s manuscript for journal publication.

Applying the constructed algorithm back to the case presented, a positive value for leukocyte esterase in an asymptomatic pregnant patient would not warrant empirical antibiotic therapy. A urine culture would have been triggered to follow-up with the leukocyte esterase, which would have revealed a non-infectious etiology, and no antibiotics would have been prescribed.

After assessing outcome improvements in accordance with the A-6 cycle’s final step,³ we can conclude the following: Don’t omit a urine culture when a urinalysis is suspicious for asymptomatic bacteriuria during pregnancy.

References

1. Urinary Tract Infections in Pregnant Individuals. Obstet Gynecol. Aug 01 2023;142(2):435-445. doi:10.1097/AOG.0000000000005269
2. O’Leary BD, Armstrong FM, Byrne S, Talento AF, O’Coigligh S. The prevalence of positive urine dipstick testing and urine culture in the asymptomatic pregnant woman: A cross-sectional study. Eur J Obstet Gynecol Reprod Biol. Oct 2020;253:103-107. doi:10.1016/j.ejogrb.2020.08.004
3. Christenson RH, Snyder SR, Shaw CS, et al. Laboratory medicine best practices: systematic evidence review and evaluation methods for quality improvement. Clin Chem. Jun 2011;57(6):816-25. doi:10.1373/clinchem.2010.157131

Sarah Bergbower is Associate Professor of Life Sciences at IECC Olney Central College in Olney, Illinois.

Table 1. Point of Care Dipstick, Day 1

Table 2. Urinalysis with Reflex, Day 2