Microbiology and Infectious Disease / SYSMEX UF-100 IN COMMUNITY-ACQUIRED UTI

Evaluation of the Sysmex UF-100 Urine Cell Analyzer as a Screening Test to Reduce the Need for Urine Cultures for Community-Acquired Urinary Tract Infection
Shine Young Kim, MD,1 Young Jin Kim, MD,1 Sun Min Lee, MD,1 Sang Hyun Hwang, MD,1 Hyung Hoi Kim, MD,1 Han Chul Son, MD,1 and Eun Yup Lee, MD1,2
Key Words: Urinary tract infection; Urine flow cytometer
DOI: 10.1309/4606EC29U50DVAFY

Abstract
We evaluated the UF-100 flow cytometer (TOA Medical Electronics, Kobe, Japan) as a screening test for community-acquired urinary tract infection (UTI) to reduce the need for bacterial cultures. By comparing the test results for 330 urine samples with quantitative urine cultures, we established cutoff criteria for the UF-100. To rule out hospital-acquired UTI, all urine samples were from new patients who had not been admitted to a hospital within the previous month. A bacterial cutoff value of 3,000/L provided the best discrimination for community-acquired UTI, with a sensitivity of 94.4% and a specificity of 73.4% compared with urine culture. It was possible to forgo 58.2% of cultures with only 4 false-negative results. With a bacterial cutoff value of 1,500/L, the sensitivity improved to 100%, but the specificity declined to 49.8%, and only 38.5% of cultures could be avoided without any false-negative results. Screening with the UF-100 for community-acquired UTI is acceptable for routine use. It would improve the efficiency of the routine microbiology laboratory, and unnecessary antibiotic prescriptions could be reduced.

Urinary tract infection (UTI) is not infrequent, and quantitative urinary culture is still the gold standard for its detection. However, approximately half of the submitted urine cultures have negative results. Urine contains many materials that give information for diagnosing UTIs, such as WBCs.1,2 Urinary sediment microscopy has been generally adopted as a testing method for analyzing WBCs and bacteria, and it is accurate for detecting UTI.3,4 However, microscopic results are difficult to reproduce consistently and is labor-intensive. The recently introduced UF-100 flow cytometer (TOA Medical Electronics, Kobe, Japan) discriminates cells and crystals in the urine and reports the quantities of each, and some data show that it is suitable as a screening test for UTI.5-8 However, most studies did not distinguish between hospitalacquired and community-acquired UTIs, yet these 2 types of samples have several differences, such as in the use or nonuse of antibiotics or catheters.9,10 In this study, we restricted the study population to patients who had not been hospitalized within the previous month to evaluate the performance of the UF-100 for community-acquired UTI. We suggest the method can reduce urine cultures for suspected community-acquired UTI by predicting culture results.

Materials and Methods

Collection of Urine Specimens From April 2006 to July 2006, 330 urine samples submitted for culture to the Clinical Microbiology Laboratory, Pusan National University Hospital, Pusan, Republic of Korea, were used. Urine specimens from inpatients or outpatients who had been hospitalized within the previous month were excluded.
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DOI: 10.1309/4606EC29U50DVAFY

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Microbiology and Infectious Disease / ORIGINAL ARTICLE

Cultures and Urinalysis UF-100 analysis and quantitative culture were applied to all 330 urine specimens. Bacterial cultures were performed by inoculation with a 10-L loop on 5% blood agar plates and MacConkey agar plates (Asan Pharmaceutical, Seoul, Korea). All plates were incubated for 24 hours at 37 in room air. The results were expressed as the number of colony-forming units (CFUs) per milliliter. Cultures were considered positive if the inoculated plate produced more than 103 CFUs/mL, which is the standard for diagnosis in pediatric patients and patients admitted to the intensive care unit in our hospital. If there were 3 or more kinds of colonies without a dominant species, the urine was considered contaminated. To identify the microorganisms, conventional biochemical tests and/or the Vitek system (bioMrieux, Riom, France) were used.11 Immediately after inoculation of the cultures, all urine specimens were analyzed for bacterial and WBC counts using the UF-100. The results were compared with the results of the urine cultures using receiver operating characteristic (ROC) analysis performed with SPSS 12.0 software (SPSS, Chicago, IL). The specificity and sensitivity of different cutoff values for WBCs and bacterial counts were calculated considering the urine culture as the reference. The cutoff values for screening for community-acquired UTI with the UF-100 were determined, along with the number of urine cultures that could have been avoided by using the different cutoff values.

cultures that produced 3,000 and 7,000 CFUs/mL. The former resulted in a bacterial count of 2,868/L and a WBC count of 0.9/L in UF-100 analysis and the latter a 3,031/L bacterial count and 15.1/L WBC count. The ROC curves for WBC and bacterial counts are given in Figure 1, in which cultures of urine specimens were taken as the reference. The area under the curve (AUC) for the bacterial count (0.931) had a higher value than the AUC for the WBC count (0.803) when 103 CFUs/mL or more was selected as the standard for a positive specimen. When 104 CFUs/mL or more was selected, the AUCs for the bacterial (0.937) and WBC (0.817) counts were slightly increased (data not shown). Table 2 shows the sensitivity and specificity of various cutoff values for bacterial counts. It indicates that 38.5% to 75.5% of unnecessary cultures could be eliminated by UF100 analysis, depending on the limit of bacterial counts. Table 3 indicates the changes in sensitivity and specificity if UF-100 screening is considered positive when at least 1 of the 2 values, bacterial or WBC count, exceeds the cutoff value. Regarding bacterial counts, 3,000/L was selected because it showed reasonable performance from the viewpoint of sensitivity and specificity in the ROC analysis. Because there was no culture-positive specimen that exceeded the WBC cutoff values and did not exceed the bacterial cutoff values, the WBC count does not provide any increase in sensitivity for the detection of UTI, although not using it sacrifices some specificity.

Results
Among the 330 urine specimens submitted for culture, 66 were positive, 259 negative, and 5 contaminated. The contaminated specimens were not tested further. The results of bacterial identification of the positive cultures with their colony counts are shown in Table 1. There were only 2 positive
Table 1 Microorganisms Identified in 66 Urine Cultures
Microorganism CFU Count/mL 105 105 7 ,000 105 105 105 105 105 60,000 105 30,000 105 3,000 105 20,000 105 No. of Cases 3 24 1 1 10 1 3 2 1 3 1 5 1 5 1 4 1.0

0.8

Sensitivity

0.6

Acinetobacter baumannii Escherichia coli Enterobacter cloacae Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa Staphylococcus aureus
Other Staphylococcus species Streptococcus viridans group Enterococcus faecalis

0.4

0.2 Bacterial count WBC count Reference 0.0 0.0 0.2 0.4 0.6 0.8 1.0 1 Specificity

Enterococcus (non-faecalis species) Candida species

CFU, colony-forming unit.

Figure 1 Receiver operating characteristic curve of bacterial and WBC counts on the UF-100 flow cytometer (TOA Medical Electronics, Kobe, Japan).

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Kim et al / SYSMEX UF-100 IN COMMUNITY-ACQUIRED UTI

Table 2 Parameters Including Number of Urine Cultures Made Unnecessary by UF-100 Screening Depending on Cutoff Values for the UF-100 Bacterial Count in 330 Specimens
No. of Bacteria (/L) Parameter Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) No. (%) of unnecessary cultures* No. (%) of false-negative results
*

1,500 100 49.8 35.3 100 127 (38.5) 0 (0.0)

2,000 97 .2 61 40.6 98.8 158 (47 .9) 2 (0.6)

3,000 94.4 73.4 49.3 97 .9 192 (58.2) 4 (1.2)

5,500 81.7 86.9 63 94.5 236 (71.5) 13 (3.9)

8,000 77 .5 90.7 69.6 93.6 249 (75.5) 16 (4.8)

Predicted number of unnecessary urine cultures using bacterial cutoff values from the UF-100 (TOA Medical Electronics, Kobe, Japan). False-negative UF-100 results compared with urine culture results.

Table 3 Change of Sensitivity and Specificity Values According to Cutoff for WBCs in Addition to 3,000/L for the Bacterial Count
WBCs/L 30 Sensitivity (%) Specificity (%) 94.4 62.3 60 94.4 68.1 110 94.4 70

Discussion
As a result of using antibiotics and indwelling catheters, immunosuppression, and exposure to nosocomial pathogens, urine specimens from patients who have been hospitalized have characteristics different from those of patients with community-acquired UTIs.9,10 There are several studies showing the usefulness of the UF-100 for screening for UTI, but most of them do not distinguish hospital-acquired and communityacquired infections.5-8 In the present study, only urine specimens from outpatients were used. Because bacterial culturing usually is not available in local clinics and the results of cultures are provided more than 2 days after collection, the diagnosis of UTI is performed on the basis of symptoms and, sometimes, urinalysis. In many cases, when physicians suspect that a patient has UTI by symptoms and signs, empirical antibiotics are prescribed without confirmative culture results, and patients may receive unnecessary antibiotics.12 By predicting the results of urine culture with the UF-100, the physicians who suspect community-acquired UTI could get more information, and the unnecessary prescription of antibiotics could be reduced. Also, workloads and laboratory costs could be lowered. When the urine specimens are submitted for culture, generally 1 blood agar and 1 MacConkey agar plate are applied to test for bacterial growth. The cost of a plate is $1 each. Also, routine urinalysis is applied in almost all cases regardless of the urine culture requests. The UF-100 urinalysis is completed within
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an hour, which allows culture using the same specimen. So, screening by UF-100 entails no additional cost and saves resources. The AUC and sensitivity and specificity of the bacterial count had higher values than those of the WBC count. Some earlier articles showed the effectiveness of screening for UTI with WBC plus bacterial counts,5 but those studies were not restricted to community-acquired UTI. In the present study, the WBC count was not as good as the bacterial count for screening for community-acquired UTI. Furthermore, the use of bacterial and WBC counts for screening did not show any benefit in the specificity and sensitivity compared with the bacterial count alone. Because high sensitivity and negative predictive value are required for screening tests in general, we suggest that a cutoff value for the bacterial count be applied only for the prediction of community-acquired UTI. The most balanced cutoff value for sensitivity and specificity was 3,000/L for the bacterial count on the ROC curve. With this value, the sensitivity was 94.4% and the specificity 73.2%. In this setting, the percent of unnecessary urine cultures was 58.2% with 1.2% false-negative results. However, higher sensitivity should be obtained to screen for UTI. Each laboratory may select lower cutoff values for bacterial counts to get better sensitivity or choose lower cutoff values flexibly for their own purposes to screen for community-acquired UTI and minimize urine cultures. Our suggestion is a cutoff value of 1,500/L for the bacterial count. With this value, we could reduce approximately 40% of urine cultures without any falsenegative results. Also, other techniques such as a strip test can improve the performance in predicting UTI.2,13,14 The bacterial counts generated by UF-100 analysis may be useful for screening to exclude community-acquired UTI and contribute to the reduction of unnecessary urine cultures and empirical antibiotic prescriptions.
From the 1Department of Laboratory Medicine, School of Medicine, and 2Medical Research Institute, Pusan National University, Pusan, Republic of Korea.

Am J Clin Pathol 2007;128:922-925

DOI: 10.1309/4606EC29U50DVAFY

American Society for Clinical Pathology

Microbiology and Infectious Disease / ORIGINAL ARTICLE

Supported by the Korea Research Foundation Grant funded by the Korean Government (MOEHRD) (grant KRF-2006-331E00299). Address reprint requests to Dr E.Y. Lee: Dept of Laboratory Medicine, School of Medicine, Pusan National University, Pusan 602-739, Korea.

References
1. Pappas PG. Laboratory in the diagnosis and management of urinary tract infections. Med Clin North Am. 1991;75:313-325. 2. Shin JH, Oh YS, Ryang DW. Clinical significance of routine urinalysis. Korean J Clin Pathol. 1986;6:33-40. 3. Pylkkanen J, Vilska J, Koskimies O. Diagnostic value of symptoms and clean-voided urine specimen in childhood urinary tract infection. Acta Paediatr Scand. 1979;68:341-344. 4. Hiraoka M, Hida Y, Tuchida S, et al. Diagnosis of urinary tract infection by urine microscopy using a disposable counting chamber. Scand J Clin Lab Invest. 1993;53:705-709. 5. Evans R, Davidson MM, Sim LR, et al. Testing by Sysmex UF100 flow cytometer and with bacterial culture in a diagnostic laboratory: a comparison. J Clin Pathol. 2006;59:661-662. 6. Manoni F, Valverde S, Antico F, et al. Field evaluation of a second-generation cytometer UF-100 in diagnosis of acute urinary tract infections in adult patients. Clin Microbiol Infect. 2002;8:662-668.

7. Dimech W, Roney K. Evaluation of an automated urinalysis system for testing urine chemistry, microscopy and culture. Pathology. 2002;34:170-177. 8. Kouri TT, Khknen U, Malminiemi K, et al. Evaluation of Sysmex UF-100 urine flow cytometer vs chamber counting of supravitally stained specimens and conventional bacterial cultures. Am J Clin Pathol. 1999;112:25-35. 9. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med. 2002;113(suppl 1A):5S-13S. 10. Jones RN. Impact of changing pathogens and antimicrobial susceptibility patterns in the treatment of serious infections in hospitalized patients. Am J Med. 1996;100:3S-12S. 11. National Committee for Clinical Laboratory Standards. Urinalysis and collection, transportation and preservation of urine specimens; approved guideline. Wayne, PA: NCCLS; 1995. NCCLS document GP 16-A(ISBN 1-56238). 12. McIsaac WJ, Low DE, Biringer A, et al. The impact of empirical management of acute cystitis on unnecessary antibiotic use. Arch Intern Med. 2002;162:600-605. 13. Roggeman S, Zaman Z. Safely reducing manual urine microscopy analyses by combining urine flow cytometer and strip results. Am J Clin Pathol. 2001;116:872-878. 14. Kim CS, Kim KD, Kim DC. Evaluation of usefulness of selective urine culture. Korean J Clin Pathol. 1991;11:109-115.

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