MCL NewsletterMERCY CLINICAL LABORATORY SUMMER 2017 / VOL. 17, ISSUE 3

URINE CULTURES, URINALYSIS BY DIPSTICK AND MICROSCOPIC EXAMINATION STEWARDSHIPBy Dr. Daniel Gervich

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Diagnosing and treating asymptomatic bacteriuria as urinary tract infection leads to widespread overprescribing of antibiotics. This in turn leads to colonization with multidrug resistant organisms (MDROs), Clostridium difficile infections (CDIs), and other adverse drug reactions. This also leads to misidentifying catheterized patients with asymptomatic bacteriuria as having hospital acquired catheter associated – urinary tract infection (CA-UTI) and not infrequently failing to correctly diagnose the cause of the clinical sign or symptom.

• Catheter Associated-Asymptomatic Bacteriuria (CA-ASB) should not be screened for

• Asymptomatic Bacteriuria should not be treated excepting prophylactically during the 1st trimester pregnancy (2 quality specimens) or prior to urologic surgery causing bleeding

Hooton, Bradley, et al Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America, CID 2010:50 (1 March) • 625

Asymptomatic bacteriuria is quite common, particularly in many subsets of patients that make up our hospital and nursing home populations as well as those visiting our emergency departments and urgent care centers.

LUIS CURIEL

MCL welcomes Luis Curiel as Courier Services Supervisor. Luis oversees the daily operations of couriers and has direct responsibility to administer software changes related to courier routes, vehicles, and client supply management. Luis has been a member of the MCL team

since February 2015, serving as a Lab Assistant in Specimen Management. Luis may be contacted at 515-643-2250 or lfcuriel@mercydesmoines.org.

DOUG DAVIS, MLT (ASCP)

Doug Davis is the new Client Services Supervisor. A graduate of the 1994 DMACC MLT program, he started his journey at Greene County Medical Center in Jefferson, Iowa, from 1994-2002. He then led the lab at Iowa Clinic Westlakes. In 2008, he become the Lab Supervisor at Mercy North.

Most recently, he served as Lab Supervisor at Mercy Clinics Internal Medicine Urbandale. Doug may be contacted at 515-643-2241 or ddavis2@mercydesmoines.org.

WELCOME AND CONGRATULATIONS to the following individuals who recently joined or moved to new roles at Mercy Clinical Laboratory.

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PATHOLOGISTSMatt Andres, D.O. Medical Director, Laboratory Services (515) 247-4467

Adam Bell, M.D. Pathologist | (515) 643-4516

Clinton Crowder, M.D. Pathologist | (515) 643-8532

Joseph Eaton, D.O. Pathologist | (515) 247-4352

Avina Kolareth, M.D. Pathologist | (515) 643-2876

Joseph Mitros, M.D. Pathologist | (515) 247-4462

Carolyn Pease, M.D. Pathologist | (515) 643-8533

Ramona Thompson, M.D. Pathologist | (515) 643-8638

MCL MANAGEMENT STAFFTeri Reiff, MHA, MLS (ASCP)CM Director, Laboratory Services

Mona Dinnauer, MHA, MLS (ASCP)CM Manager, Outreach Services

Andrea Jones, MLS (ASCP)CM Manager, Core Laboratory

Cristin Lantz, MLS (ASCP)CM Manager, Specimen Management

Jill Noble, MLS (ASCP)CM Manager, Specialty Services

OUTREACH STAFFLuis CurielSupervisor, Courier Services

Doug Davis, MLT (ASCP)CM

Supervisor, Client Services

Teresa McDonough, MLS (ASCP)CM

Business Development Coordinator

Lori Wallen, MLS (ASCP)CM

Technical Consultant

Jen Williams, MLS (ASCP)CM

Technical Consultant

MERCY CLINICAL LABORATORY 1111 6th Avenue Des Moines, IA 50314www.mercydesmoines.org/mcl (515) 247-4439 or (877) 263-1622

JENNIFER WILLIAMS, MLS (ASCP)

Jennifer Williams became a Technical Consultant for Mercy Clinical Laboratory in March 2017. She began her career at MCL five years ago, working as a processor while earning her Bachelor’s degree at Mercy College of Health Sciences. Soon after, Jen began working with in-patient phlebotomy. She split her time between processing and phlebotomy while finishing up her degree. She entered into the MLS program at Mercy College in the fall of 2015.

Upon graduating in August of 2016, Jen took a job working as a Med Tech on the overnight shift in core lab. Jen may be contacted at 515-643-8564 or jwilliams3@mercydesmoines.org.

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SPECIFIC IGE BLOOD TESTING AND PRIMARY CARE MANAGEMENT OF ASTHMA

Asthma presents a major clinical challenge for primary care clinicians. Generally characterized by the three key symptoms of wheezing, chronic cough and dyspnea, this disease affects ever-greater numbers of patients, young and old. Primary care clinicians are called upon to manage the care of patients with disease of varying severity, whose symptoms may be caused or exacerbated by a wide array of triggers. Asthma is generally classified as allergic or non-allergic, and distinguishing between these two types is essential to effectively reducing symptoms and controlling disease severity. Specific IgE blood testing offers primary care clinicians a valuable tool to help make this determination in order to guide asthma management.

More Americans than ever now suffer from asthma. Research indicates that:

• More than 20 million people have asthma

• 6.8 million U.S. children under 18 have been diagnosed with asthma

• 60 percent of those with asthma suffer specifically from allergic asthma

• Up to 90% of asthmatic children have been reported to be atopic

The above statistics illustrate how often allergy can play a central role in asthma onset and severity. While more than half of all asthmatics have allergic asthma, even higher numbers are shown to have asthma and concomitant allergic rhinitis (AR) at rates estimated between 60% and 99%. In fact, evidence increasingly supports the “one airway theory,” which holds that the upper respiratory inflammation caused by AR can contribute to inflammation in the lower airway. Because these conditions so often co-exist, experts recommend testing for and treating concomitant allergic rhinitis to aid asthma management and reduce disease severity. continued on page 3

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Trigger avoidance has become a cornerstone of asthma management to effectively reduce disease symptoms and severity. Guidelines from the NIH urge identification of allergens and other irritants to reduce exposure to these triggers. These asthma recommendations also advocate the use of specific IgE blood testing as an option for primary care clinicians to assess for atopy in order to guide asthma management.

The NIH National Asthma Education and Prevention Program (NAEPP) expert panel report, Guidelines for the Diagnosis for the Diagnosis and Management of Asthma, offers the following allergy assessment recommendations:

• Exposure of asthma patients to irritants or allergens to which they are sensitive has been shown to increase asthma symptoms and precipitate asthma exacerbations

• For at least those patients with persistent asthma on daily medications, the clinician should:

- Identify allergen exposures

- Use patient history to assess sensitivity to seasonal allergens

• Use skin testing or in vitro testing for IgE antibodies to assess sensitivity to perennial indoor allergens

• For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for avoidance, for immunotherapy, or to characterize the patient’s atopic status

- Assess the significance of positive tests in the context of the patient’s medical history

• Patients with asthma at any level of severity should avoid exposure to allergens to which they are sensitive

In children, allergic asthma commonly results from a cascade of atopic illnesses known as the pediatric Allergy March. In the Allergy March, symptoms manifest from food and inhalant sensitivities and trigger a progression of diseases from atopic dermatitis to gastrointestinal complaints, recurrent ear infections, allergic rhinitis, and ultimately asthma—often by the age of 3 to 4 years. Research indicates that early intervention (through such measures as avoidance, antihistamine treatment and immunotherapy) can help to reduce acute allergy symptoms and may interrupt the development of asthma.

In these young patients, wheezing is a key lower respiratory symptom. To help clinicians determine

which wheezers might develop asthma, the authors of the landmark Tucson Children’s Respiratory Study devised the Asthma Predictive Index. In the index, asthma is more probable in children who have had recurrent episodes of wheezing during the previous year, along with risk factors including atopic dermatitis or allergic rhinitis. Both these common childhood illnesses can be confirmed using specific IgE blood testing.

ALLERGY TESTING IN PRACTICE Regional specific IgE respiratory profile test results can help determine IgE sensitizations (which is key to determining whether or not a patient has allergic asthma). It will then identify and quantify the degree of IgE sensitization to those allergens (triggers) that can cause an asthma episode. If specific IgE sensitization is not detected to any of the profile allergens, the clinician can then focus on other evaluations to determine non-allergic triggers (which can include infection, tobacco smoke, exercise/stress, and non-atopic occupational exposures).Used in conjunction with the patient history and physical exam, specific IgE blood testing offers a relatively convenient and highly accurate diagnostic option in primary care.

Current modalities are far superior to earlier forms of IgE testing using RASTTM. With greater than 95% sensitivity in patients with atopy and an accuracy equivalent to skin testing, specific IgE blood testing not only determines the presence of atopy but also identifies—and quantifies—specific allergic sensitivities. In vitro testing employs a single blood draw to test for multiple inhalant and food allergens through pre-selected respiratory disease and pediatric profiles. Results are available to the clinician in 2 to 3 days, reported in quantitative values that clearly and objectively indicate the degree of allergic sensitization.

SPECIFIC IGE BLOOD TESTING HELPS CLINICIANS:Identify allergic triggers and develop a diagnosis / Develop and implement a personalized plan to manage allergic and non-allergic symptoms / Comply with guidelines-based asthma care

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Asthma continued from page 2

For more than sixty years, Wayne County Hospital and Clinic System (WCHCS) has provided wellness and critical care to a remote, rural population in south central Iowa. Our goal is to provide the best possible healthcare for our community comprised of a predominately elderly, low-income population with a higher propensity for chronic conditions. Since 1986, WCHS has had a management agreement with Mercy Medical Center - Des Moines and is part of the statewide collaborative Network of Healthcare Services.

We are a 25-bed, critical access hospital providing general medical/surgical services and operate four family practice rural health clinics in the county. Our employed medical staff consists of ten physicians, two dentists and 11 mid-level professionals. We are equipped with digital imaging and up-to-date laboratory services. WCHCS operates using electronic health record systems; Centriq on the hospital side and Greenway in the clinic system, which include patient portals that provide patients easy access to their personal medical records to schedule appointments, request prescription refills and pay bills online.

WCHCS provides obstetrics for a five-county area and delivers more babies than nearly all Iowa hospitals our size. Our growing orthopedic program not only performs hip, knee and shoulder replacements, but also promotes joint preservation and restoration, and repairs to injuries specific to the farm and labor workforce. Additional, WCHCS services include cardiac rehabilitation; eICU care which provides a remote monitoring capability through a partnership with St. Lukes Hospital in Kansas City for patients with a higher acuity level; inpatient and outpatient rehabilitation therapy; women’s health services; oncology and infusion treatments; dialysis services; a wound care clinic; and specialty clinic for our visiting physicians.

The WCHCS Laboratory provides services in hematology, coagulation, immunohematology, chemistry and urinalysis, performing over 120,000 tests per year. Reference laboratory testing is coordinated with Mercy Clinical Laboratory, LifeServe Blood Center and State of Iowa Hygienic Laboratory. Providing an essential service, the laboratory service is provided 24 hours a day all days of the year. The laboratory is staffed with five laboratory technologists and two patient service representatives.

The nearest urban area for advanced medical care is Des Moines, Iowa, located 75 miles to the north. Our Level IV emergency department provides essential 24-hour emergency care and offers stabilization and transfer services via ambulance or medical helicopter to larger facilities throughout the state for patients requiring more specialized care.

With 257 employees, WCHCS is among the top employers in our community. The March 2016 Iowa Hospital Association Economic Impact study reported WCHCS as having a $17.5 million impact on Wayne County’s local economy. WCHCS is dedicated to providing comprehensive medical services of the highest quality, in the most cost-effective manner, while constantly improving excellence in the best interest of patient care. For more information please go to www.waynecountyhospital.org or call 641-872-2260.

PARTNER PROFILE

WAYNE COUNTY HOSPITAL AND CLINIC SYSTEM CARING FOR GENERATIONS

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Lab staff, left to right, Karen Richardson, Lab Director; TommyJessen, Technologist; Megan Hopkins, Chief Technologist

Table 1: Prevalence of asymptomatic bacteriua in select populations

References available on request

In a study of hospitalized patients in a large city hospital similar to ours, the rate of bacteriuria in catheterized patients was 51% and was 18.6% among non-catheterized patients. Leis, Rebick, et al Reducing Antimicrobial Therapy For Asymptomatic Bacteriuria Among Non-Catheterized Inpatients: A Proof Of Concept Study, CID 2014;58:980-983

These numbers contribute to a high probability of a false positive result when relied upon to confirm a diagnosis of UTI.Mercy Laboratory Services, our Healthcare Epidemiology and Infection Prevention Departments and the Antibiotic Stewardship program of the Pharmacy support guidelines and recommendations to only obtain urine cultures in symptomatic patients who are at substantial risk.

Localizing Signs and Symptoms Compatible With CA-UTI Include:• Flank pain

• Costovertebral angle tenderness

• Acute hematuria; pelvic discomfort;

• In those who do not have catheters or whose catheters have been removed: dysuria, urgent or frequent urination, or suprapubic pain or tenderness.

Hooton, Bradley, et al Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America, CID 2010:50 (1 March) • 625

Not Signs or Symptoms Indicative of UTI and not Indications for a U/A or a Urine Culture:• Altered mental status*

• Malaise, or lethargy with no other identified cause*

• Cloudy urine, urine sediment, foul smelling urine, dark urine

• Indwelling catheter

Schulz, Hoffman, et al, Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections, J. Emerg. Med. 2016;51(1):25-30.Sloane, Kistler, et al, Urine culture Testing in Community Nursing Homes: Gateway to Antibiotic Overprescribing, Infect Control Hosp Epidemiol, May 2017;38:524–531

* While mental status change, lethargy and the like have long be cited as potential signs of UTI particularly in the geriatric, dementia and brain injury patients, this notion has more recently been repeatedly disproven in scientific studies. Often the reasons for these fluctuations in status remain unexplained. There are recent publications in the Neurology literature pointing to misdiagnosis of small strokes and other neurological or adverse medication responses as UTI resulting from misinterpretation of prevalent asymptomatic bacteriuria in these populations. Of course altered mental status does occur in the context of sepsis syndrome.

Evaluating Fever in a Sepsis Work-up:• UTI is an infrequent cause of hospital acquired Sepsis

Syndrome, (0.4% – 0.7% of cases of bacteremia)

• Urine cultures should only be evaluated in hospital patient populations at high risk of invasive infection.

– Those who are kidney transplant recipients

– Those who are neutropenic

– Those who have recently had genitourinary surgery

– Those who demonstrate evidence of obstructionO’Grady, Barie, Bartlett, et al, Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med 2008; 36: 1330-1349

We recommend urine cultures are only ordered for evidence-based reasons. Our goal is to limit urine culture orders on asymptomatic patients to those in their first trimester of pregnancy, or prior to urologic surgery causing bleeding. In addition, work is being done to educate nurses and providers on which signs and symptoms are indicative of community acquired UTI and in need of testing, and which symptoms are not. By embracing a more disciplined approach with a focus on the decision to test, a “pre-culture” strategy of applying stewardship to laboratory diagnostics, we will improve diagnostic accuracy, antibiotic stewardship, outcomes and hospital CA-UTI rates.

These recommendations have been published by the Infectious Diseases Society of America, The International Infectious Diseases Society, The American Society of Microbiology, The American Collage of Critical Care Medicine, as well as being supported by The American Geriatrics Society, The Society for Post-Acute and Long-Term Care Medicine and The American Congress of Rehabilitation Medicine.

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MCL PATIENT SERVICE CENTERS MCL patient service centers provide prompt, quality service in the five locations listed below. The hospital outpatient phlebotomy stations are based on hospital property: therefore, patients must be registered through the hospital and charges are based on a hospital stay. This generally increases the wait time for a blood draw. The hospital outpatient areas are designed to serve patients who need multiple outpatient services including lab; hence the visit could be coordinated.

FOR A BASIC BLOOD DRAW, please utilize one of our four patient service centers.

MCL Mercy North 800 E. First St., Ste. 1400, AnkenyPhone: (515) 643-7710 Fax: (515) 643-8176Hours: Monday – Friday, 7 a.m. to 4 p.m. (Closed noon - 1 p.m. for lunch)

MCL Mercy West 1601 NW 114th St., Ste. 134, ClivePhone: (515) 222-7500 Fax: (515) 222-7510Hours: Monday – Friday, 7 a.m. to 5 p.m.

MCL Atrium – Mercy Medical Plaza 411 Laurel St., Level A, Ste. 265, Des MoinesPhone: (515) 643-8924 Fax: (515) 643-8239Hours: Monday – Friday, 6 a.m. to 5 p.m.

MCL Westown – Medical Office Building 5901 Westown Pkwy., Ste. 236, West Des MoinesPhone: (515) 358-7790 Fax: (515) 358-7791Hours: Monday – Friday, 8 a.m. to 4:30 p.m. (Closed noon - 1 p.m. for lunch)

MERCY OUTPATIENT PHLEBOTOMY

Mercy Medical Center1111 6th Ave., Main Entrance, Des MoinesPhone: (515) 247-3020 Fax: (515) 643-8552Hours: Monday – Friday, 6 a.m. to 4:30 p.m.

Mercy West Lakes 1755 59th Pl., Ste. 2260, West Des MoinesPhone: (515) 358-8150 Fax: (515) 358-8987Hours: Monday – Friday, 7 a.m. to 5 p.m.