Journal Club

Diagnostic Stewardship in Neutropenic Fever: Low Utility of Urine Cultures Without Symptoms

By Christopher J. Graber, MD, MPH, FIDSA

Workup for source and initiation of empiric antimicrobial therapy for patients with neutropenic fever following hematopoietic stem cell transplantation is well-validated. Results of this workup then influence the subsequent course of treatment. Urine cultures are typically included as a part of a “pan-culture” approach, but it is unclear just how much they add in patients who do not have symptoms suggestive of urinary tract infection.

In an article in Open Forum Infectious Diseases, authors from the University of North Carolina examined 667 adult patients presenting with febrile neutropenia following hematopoietic stem cell transplantation (HSCT) who had urine cultures performed during their initial febrile neutropenia episode and no prior documented urinary tract infection occurring within 7 days of admission for HSCT. None had urinary catheterization, and all were receiving antimicrobial prophylaxis at the time of transplant, most commonly levofloxacin (92%).

Only one patient reported urinary symptoms and had a positive urine culture with a coagulase-negative Staphylococcus; six other patients had urinary symptoms with negative urine culture that were attributed to BK cystitis (n = 5) or chemotherapy toxicity (n = 1). Forty (6%) patients had asymptomatic bacteriuria, of which the majority were female. Coagulase-negative staphylococci were isolated in almost half of asymptomatic bacteriuria episodes; only six Gram-negative rods were found. Antibiotic changes were made in only three patients based on urine culture results; none were necessarily warranted as judged by the investigators. No patients with asymptomatic bacteriuria died within 30 days post-transplant.
 
Based on this single-center study, the utility of ordering urine cultures in the context of neutropenic fever following HSCT in patients without urinary symptoms seems low. Further study is needed in other conditions associated with febrile neutropenia and in patients with indwelling urinary catheters.

(Tran et al. Open Forum Infect Dis. Published online: May 3, 2023)