Is reflex (automatic performance of a culture) the same as a culture and sensitivity (C&S) test?

Reflex Testing vs. Culture and Sensitivity (C&S)

No, reflex testing is not the same as a culture and sensitivity (C&S) test. Reflex testing refers to an automated process where a laboratory performs additional tests on a specimen based on predetermined criteria from initial test results, while a C&S test specifically involves growing microorganisms and testing their susceptibility to antimicrobials.

Understanding Reflex Testing

Reflex testing is a laboratory practice where:

• Initial test results that meet specific criteria automatically trigger additional testing without requiring a new order from the healthcare provider 1
• It's designed to improve diagnostic efficiency, reduce unnecessary testing, and support antimicrobial stewardship 1
• Common examples include:
  • Urinalysis with reflex to culture - when initial urinalysis shows signs of infection (like pyuria or bacteriuria), the specimen is automatically cultured 2, 3
  • Reflex testing for C. difficile - using algorithms to determine when additional confirmatory testing is needed 1
  • HPV testing - reflex testing for high-risk HPV genotypes in women with certain cytology results 1

Understanding Culture and Sensitivity (C&S)

Culture and sensitivity testing is a specific laboratory procedure that:

• Involves growing microorganisms from a patient specimen on specialized media 1
• Identifies the specific pathogen(s) present in the specimen 1
• Tests the isolated organism's susceptibility to various antimicrobial agents 1
• Provides guidance for targeted antimicrobial therapy 1

Key Differences

The fundamental differences between reflex testing and C&S include:

• Purpose: Reflex testing is a workflow process that determines when additional tests should be performed, while C&S is a specific microbiological test methodology 1
• Timing: Reflex testing occurs based on initial test results, while C&S is either ordered directly or triggered by reflex criteria 2, 3
• Scope: Reflex testing applies to many laboratory disciplines (microbiology, cytology, serology), while C&S is specifically a microbiology procedure 1

Clinical Applications and Considerations

Reflex Testing in Microbiology

• Urinalysis with reflex to culture has become a common practice to reduce unnecessary cultures 2, 4
• Studies show varying positive predictive values for reflex criteria:
  • Some studies report PPVs as high as 91% 4
  • Others report lower PPVs around 58% 5
• Reflex criteria typically include parameters such as:
  • White blood cell count (≥5 WBCs per HPF) 4, 5
  • Presence of bacteria 4, 5
  • Nitrite positivity 4
  • Leukocyte esterase positivity 4

Potential Pitfalls

• Reflex testing may sometimes lead to inappropriate antibiotic use when initial screening tests are positive but subsequent cultures are negative 6
• In one study, 30.5% of patients with positive urine screen but negative culture received antibiotics compared to 7.1% with negative screens 6
• Reflex criteria vary between institutions due to lack of standardized evidence-based guidelines 2, 5
• Implementation requires careful consideration of laboratory workflow, cost implications, and antimicrobial stewardship goals 2, 3

Best Practices

• Reflex testing should be implemented with clear, evidence-based criteria that have high positive predictive values 4
• Regular evaluation and optimization of reflex criteria can improve laboratory efficiency and reduce unnecessary antibiotic use 4, 5
• Clinicians should be educated about the meaning of reflex testing results to avoid inappropriate antimicrobial therapy based solely on screening test results 6