The role of point‐of‐care tests in antibiotic stewardship for urinary tract infections in a resource‐limited setting on the Thailand–Myanmar border

Abstract

ObjectivePublished literature from resource‐limited settings is infrequent, although urinary tract infections (UTI) are a common cause of outpatient presentation and antibiotic use. Point‐of‐care test (POCT) interpretation relates to antibiotic use and antibiotic resistance. We aimed to assess the diagnostic accuracy of POCT and their role in UTI antibiotic stewardship.MethodsOne‐year retrospective analysis in three clinics on the Thailand–Myanmar border of non‐pregnant adults presenting with urinary symptoms. POCT (urine dipstick and microscopy) were compared to culture with significant growth classified as pure growth of a single organism >105 CFU/ml.ResultsIn 247 patients, 82.6% female, the most common symptoms were dysuria (81.2%), suprapubic pain (67.8%) and urinary frequency (53.7%). After excluding contaminated samples, UTI was diagnosed in 52.4% (97/185); 71.1% (69/97) had a significant growth on culture, and >80% of these were Escherichia coli (20.9% produced extended‐spectrum β‐lactamase (ESBL)). Positive urine dipstick (leucocyte esterase ≥1 and/or nitrate positive) compared against positive microscopy (white blood cell >10/HPF, bacteria ≥1/HPF, epithelial cells <5/HPF) had a higher sensitivity (99% vs. 57%) but a lower specificity (47% vs. 89%), respectively. Combined POCT resulted in the best sensitivity (98%) and specificity (81%). Nearly one in ten patients received an antimicrobial to which the organism was not fully sensitive.ConclusionOne rapid, cost‐effective POCT was too inaccurate to be used alone by healthcare workers, impeding antibiotic stewardship in a high ESBL setting. Appropriate prescribing is improved with concurrent use and concordant results of urine dipstick and microscopy.

A current perspective on antimicrobial resistance in Southeast Asia

“… 34 , 71 , 72 An additional investigation showed that the concurrent use of two point-of-care rapid tests (urine dipstick and microscopy) improved antimicrobial prescribing in adults with urinary tract infections at the Thailand–Myanmar border. 73 …”

Predictive value of the urinary dipstick test in the management of patients with urinary tract infection-associated symptoms in primary care in Indonesia: a cross-sectional study

“…Despite proper guidance on using the dipstick test result in a rule-out strategy for UTI, over 50% of participants with UTI-associated symptoms but with a negative dipstick result were prescribed antibiotics. 17 …”

An opportunity for global antimicrobial stewardship research: Refugee populations

“…24 Another study at the Thailand-Myanmar border found that in a population largely comprised of migrants and refugees, combined pointof-care testing of urinary tract infections (urine dipstick and microscopy together) improved appropriate antimicrobial prescribing, showing the use of only one test (urine dipstick or urine microscopy alone versus both tests combined when compared to urine culture as the gold standard) to be ineffective in the setting of high prevalence of multidrug resistance in the area. 25 A qualitative, cross-sectional study in which Palestinian refugees at Jordanian refugee camps were interviewed revealed high prevalence of inappropriate antibiotic use, poor knowledge base of antibiotic side effects and resistance, and long wait times to see providers, preventing refugees from seeking medical advice. 26 Most inappropriate use was attributed to over-thecounter acquisition of antibiotics without a prescription and self-medication at home or the use of leftover antibiotics from social contacts.…”