Application and evaluation of HB&L system in the rapid diagnosis of urinary tract infection

Abstract

Background

Urinary tract infections (UTIs) are among the most prevalent bacterial infections worldwide, impacting millions annually. Traditional urine culture, the gold standard for UTI diagnosis, is associated with limitations such as lengthy culture times (24–48 hours), which can delay treatment. Additionally, the increasing prevalence of antibiotic resistance further emphasizes the need for rapid diagnostic methods to enhance clinical decision-making and reduce the unnecessary use of antibiotics. The HB&L system, developed by ALIFAX, presents a promising alternative that could potentially shorten diagnostic times, improving both treatment speed and patient outcomes. This study aims to evaluate the efficacy of the HB&L system for the rapid diagnosis of UTIs, comparing its performance with traditional urine culture methods, and to explore its feasibility and potential advantages in clinical practice.

Methods

From June 2023 to February 2024, midstream urine samples were collected from 409 suspected UTI patients treated at The First Affiliated Hospital of Guangzhou Medical University. The samples were analyzed using both traditional urine culture methods and the HB&L system, with concurrent urinalysis results obtained from the same specimens. Traditional urine culture served as the reference standard to evaluate the diagnostic performance of the HB&L system and urinalysis for detecting UTIs. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the agreement between the methods. The Kappa coefficient was used for statistical analysis to determine the level of concordance.

Results

The HB&L system demonstrated a sensitivity of 89.77%, specificity of 96.88%, PPV of 88.76%, NPV of 97.19%, and a Kappa coefficient of 0.86, indicating a high degree of concordance with traditional culture methods. In contrast, the Kappa coefficients for urinalysis parameters were 0.11 for protein, 0.08 for leukocyte esterase, and 0.44 for nitrite. The combined Kappa coefficient for these three infection-related urinalysis indicators was 0.11. The HB&L system provides results within 4.5 hours, whereas traditional methods typically require 24–48 hours. Overall, the diagnostic performance of urinalysis was inferior to that of the HB&L system.

Conclusions

The HB&L system has significant advantages in the rapid and accurate diagnosis of UTIs, making it a potential alternative or complement to traditional urine culture methods.

Highlight box.

Key findings

• The HB&L system (a proprietary system by ALIFAX for rapid microbial detection) shows high agreement with traditional urine culture (sensitivity 89.77%, specificity 96.88%, Kappa 0.86) and provides results in 4.5 hours, far faster than the 24–48 hours of traditional methods. Routine urinalysis indicators and their combination perform poorly (Kappa 0.08–0.44). HB&L accurately identifies common pathogens, especially Gram-negative bacilli, with limitations in rare/mixed infections.

What is known and what is new?

• Urinary tract infections (UTIs) are common, with traditional urine culture as the gold standard but requiring 24–48 hours, delaying treatment and fueling antibiotic resistance. Routine urinalysis (protein, leukocyte esterase, nitrite) performs poorly for diagnosis.

• This study evaluates the HB&L system, finding it has high sensitivity (89.77%) and specificity (96.88%) for UTI diagnosis, with strong agreement (Kappa 0.86) with traditional culture. It provides results in 4.5 hours, far faster than traditional methods (24–48 hours), and outperforms routine urinalysis. It also details pathogen detection accuracy, especially for Gram-negative bacilli.

What is the implication, and what should change now?

• HB&L can rapidly and accurately diagnose UTIs, aiding timely treatment and reducing antibiotic misuse. It should complement traditional culture, especially for rapid screening. Future efforts: validate in multicenters, improve detection of rare/mixed infections, and assess cost-effectiveness.

Introduction

Urinary tract infection (UTI) is a common infectious disease caused by pathogens invading the urinary tract, primarily affecting the urethra, bladder, ureters, and kidneys (1-4). UTI is the most common hospital-acquired infection, impacting millions of people worldwide. It can occur at any age but is particularly prevalent among women, the elderly, and immunocompromised patients (5). Statistics indicate that approximately 50% of women will experience at least one UTI in their lifetime (6). UTIs not only significantly reduce the quality of life for patients but can also lead to severe complications such as acute pyelonephritis and sepsis, increasing medical burdens and the risk of hospitalization (7,8). According to the World Health Organization (WHO), UTIs are one of the leading causes of increased hospitalization and medical expenses globally, with UTI-related healthcare costs amounting to billions of dollars annually (9,10). Currently, the diagnosis of UTI primarily relies on urine culture and routine urinalysis. Traditional urine culture is considered the “gold standard” for UTI diagnosis, but it has significant limitations, such as lengthy culture time that typically requires 24–48 hours to yield results, potentially delaying clinical treatment (11). These limitations often lead to erroneous empirical treatments in clinical practice, increasing the misuse of antibiotics and the risk of antibiotic-resistant bacteria, potentially masking the actual pathogens and complicating subsequent treatments (12,13). In the context of growing antibiotic resistance, accurate and rapid UTI diagnosis is critically important. The limitations of traditional methods necessitate a diagnostic tool that can provide highly accurate results in a short time (14,15).

The HB&L system (a proprietary system by ALIFAX, Padova, Italy) is a novel automated urine microbial detection system that combines optical density and biochemical reaction methods, providing preliminary UTI diagnostic results within a few hours. This system offers high sensitivity and specificity, enabling rapid and accurate detection of bacteria and yeast in urine (16). Studies have shown that the HB&L system correlates well with traditional culture methods, detecting bacterial growth rapidly and accurately. In one study, it was able to detect bacterial growth in 21.2% of samples within a 4-hour protocol, closely matching the results obtained through conventional culture methods, which had a 22% positivity rate (17). The inclusion of the residual antimicrobial activity test enhances diagnostic accuracy by identifying patients on antimicrobial treatment, thus avoiding false-negative results and ensuring precise diagnostics. Furthermore, the combination of HB&L with mass spectrometry {matrixassisted laser desorption/ionizationtime-of-flight mass spectrometry [MALDI-TOF MS (bioMérieux SA, Manchester, UK)]} accelerates pathogen identification from 39–48 hours to approximately 4–6 hours, significantly improving UTI diagnosis speed and reliability.. Despite the promise of molecular diagnostics and mass spectrometry in recent years, the HB&L system’s unique advantages of automation and rapid response make it particularly appealing for clinical use (18).

This study aims to evaluate the effectiveness of the HB&L system in the rapid diagnosis of UTIs. By comparing it with traditional urine culture methods, we aim to explore the feasibility and advantages of the HB&L system in clinical applications and further validate its potential as a rapid diagnostic tool for UTIs. The results of this study will provide new evidence for the rapid diagnosis of UTIs and may promote improvements and optimization in clinical diagnostic practices. We present this article in accordance with the STARD reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-107/rc).

Methods

Sample source

This study included mid-stream urine samples from 409 patients suspected of having UTIs, who were treated at The First Affiliated Hospital of Guangzhou Medical University between June 2023 and February 2024. Among these, urine samples from 394 patients were simultaneously collected for routine urinalysis. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University (approval number: ES-2023-229-01). Written informed consent was obtained from all participants prior to sample collection and testing.

Traditional midstream urine culture

A total of 409 midstream urine samples were collected from patients suspected of having a UTI and transported to the microbiology laboratory within 2 hours of clinical collection to ensure sample integrity. Using a calibrated 10 µL inoculating loop, the samples were quantitatively streaked onto Columbia blood agar plates using the quadrant streak method. The plates were incubated at 37 ℃ in a 5–10% CO₂ atmosphere for 24–48 hours to allow for bacterial growth. Samples with bacterial counts exceeding 1×10⁴ cfu/mL were considered UTI positive, while those with lower counts were deemed negative (19). For fungal detection, a positive threshold of 1×10³ cfu/mL was set (20). Colony counting was performed for samples showing two or fewer types of bacteria. If high bacterial concentrations prevented the isolation of individual colonies, samples were re-inoculated onto fresh Columbia blood agar plates for further separation and cultivation.

For mass spectrometry identification, samples with bacterial counts exceeding 1×10⁴ cfu/mL were selected. Bacterial colonies from the culture plates were transferred to a target plate for mass spectrometry analysis, with bacterial identification based on the mass-to-charge ratio (m/z) of bacterial proteins. If mixed infections were observed, a fresh Columbia blood agar plate was used to isolate each bacterial species separately, followed by incubation at 37 ℃ in a 5–10% CO₂ atmosphere for 24–48 hours. Each isolated bacterial strain was then subjected to MALDI-TOF MS for individual identification, ensuring precise pathogen identification.

Microbiological analysis using the HB&L system

For the HB&L system analysis, 500 µL of midstream urine sample was inoculated into urine culture bottles provided by ALIFAX. The HB&L system was set to incubate for 4.5 hours (5,17). Samples yielding no positive results were reported as negative. For samples yielding positive results, 1 mL of culture fluid was transferred to an Eppendorf tube and centrifuged at 12,000 rpm for 2 minutes. The resulting pellet was used for Gram staining and microscopy, followed by mass spectrometry analysis. The system’s automatic counts, positive reporting time, and turbidity information were recorded.

For samples indicating mixed infections, where more than two types of bacteria were observed under microscopy after staining, the original 10 µL midstream urine sample was inoculated onto Columbia blood agar plates. These plates were incubated at 37 ℃ in a 5–10% CO₂ atmosphere for 24–48 hours, followed by manual colony counting and recording. Bacteria grown on the plates were individually subjected to mass spectrometry identification (Figure 1).

Figure 1.

Technical flow roadmap for rapid diagnosis and pathogen identification of urinary tract infection based on HB&L system.

In this study, all HB&L system tests were performed in a blinded manner. The test personnel were unaware of the patient’s clinical information or the reference standard results (traditional urine culture) when conducting the index test. This approach was designed to ensure that the test results were not influenced by any prior information, thereby minimizing potential bias and enhancing the objectivity and reliability of the study.

Routine urinalysis

Among the 409 samples, urine samples from 394 patients were simultaneously subjected to routine urinalysis using the Sysmex UC3500 urine analyzer (Sysmex Corporation, Kobe, Japan). Specific parameters measured included urine protein (PRO), leukocyte esterase (LE), and nitrite (NIT).

Statistical methods

Statistical analysis was performed using R software (version 4.3.1) to evaluate the performance of different diagnostic methods. Preliminary analysis involved calculating basic statistics, such as mean and standard deviation for continuous variables, and frequencies and percentages for categorical variables. These descriptive statistics provided an overview of the study sample’s basic characteristics, including age, gender distribution, and routine urinalysis results.

To evaluate diagnostic performance, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) using metrics derived from the confusion matrix, with traditional urine culture results serving as the reference standard. Sensitivity was calculated as $\frac{Truepositive}{Truepositive+Falsenegative}$, specificity as $\frac{Truenegative}{Truenegative+Falsepositive}$, PPV as $\frac{Truepositive}{Truepositive+Falsepositive}$, and NPV as $\frac{Truenegative}{Truenegative+Falsenegative}$.

The Kappa coefficient was calculated to assess the agreement between HB&L detection and traditional urine culture results, accounting for the effect of chance agreement and providing a measure of consistency between the two test results. All statistical tests were two-sided. Adobe Illustrator was employed for color and layout optimization, as previously described (21-23).

Results

Traditional culture results

Among the 409 midstream urine samples, traditional culture results identified 88 positive cases and 321 negative cases. Among the positive cases, 27 involved Gram-positive bacteria, 47 involved Gram-negative bacteria, 8 involved yeast, and 6 involved mixed infections.

Comparison of HB&L rapid detection results with traditional culture results

The HB&L system was used to test 409 urine samples over 4.5 hours, resulting in 89 positive and 320 negative results. The comparison between HB&L system results and traditional culture results is as follows: 79 samples were positive in both traditional culture and HB&L detection; 9 samples were positive in traditional culture but negative in HB&L detection; 10 samples were negative in traditional culture but positive in HB&L detection; and 311 samples were negative in both methods (Table 1).

Table 1. Pathogens in comparative study between traditional urine culture and HB&L methods.

Detection grouping	HB&L+	HB&L−
BACTEC+	Escherichia coli (n=25), Klebsiella pneumoniae (n=7), Enterococcus faecium (n=6), Streptococcus agalactiae (n=6), Enterococcus faecalis (n=5), Candida glabrata (n=4), Proteus mirabilis (n=3), Staphylococcus haemolyticus (n=3), Staphylococcus aureus (n=2), Enterobacter cloacae (n=2), Candida albicans (n=1), Staphylococcus epidermidis (n=1), Enterobacter aerogenes (n=1), Klebsiella aerogenes (n=1), Klebsiella oxytoca (n=1), Lactococcus garvieae (n=1), Streptococcus gallolyticus (n=1), Candida parapsilosis (n=1), Citrobacter koseri (n=1), Morganella morganii (n=1), Candida tropicalis (n=1), Escherichia coli/Klebsiella pneumoniae (n=1), Escherichia coli/Streptococcus agalactiae (n=1), Escherichia coli/Candida glabrata (n=1), Escherichia coli/Proteus mirabilis (n=2), total number (n=79)	Escherichia coli (n=4), Enterococcus faecium (n=1), Staphylococcus haemolyticus (n=1), Enterobacter aerogenes (n=1), Escherichia coli/Enterococcus faecalis (n=1), Candida albicans (n=1), total number (n=9)
BACTEC−	Total number (n=10)	Total number (n=311)

BACTEC+, traditional urine culture found bacteria; BACTEC−, traditional urine culture found not bacteria; HB&L+, HB&L report positive; HB&L−, HB&L report negative.

The HB&L system demonstrated an observed agreement (P_o) of 95.35%, a sensitivity of 89.77%, and a specificity of 96.88%. The PPV was 88.76% and the NPV was 97.19%. The Kappa coefficient was 0.86 (Table 2), indicating a high level of agreement between HB&L and traditional urine culture, showcasing its excellent diagnostic capability.

Table 2. Performance metrics of urine routine indicators and HB&L in detecting urinary tract infections compared to traditional culture method.

Detection indices	Sensitivity (%)	Specificity (%)	PPV (%)	NPV (%)	LR+	LR−	P_o (%)	Cohen’s Kappa
PRO	52.44	51.60	22.10	80.50	1.08	0.92	55.94	0.11
LE	76.83	50.00	28.75	89.12	1.54	0.46	55.66	0.08
NIT	32.93	96.80	72.97	84.58	10.29	0.69	83.53	0.44
UTCD	90.24	31.73	25.78	92.52	1.32	0.31	43.93	0.11
HB&L	89.77	96.88	88.76	97.19	28.77	0.11	95.35	0.86

LE, leukocyte esterase; LR+, positive likelihood ratio; LR−, negative likelihood ratio; NIT, nitrate; NPV, negative predictive value; P_o, observed agreement; PPV, positive predictive value; PRO, urine protein; UTCD, three indexes of urine routine combination for diagnosis.

Comparison of routine urinalysis results with traditional urine culture

In this study, a total of 409 midstream urine samples were collected, but due to sample collection limitations, we successfully obtained 394 remaining urine samples from patients. These samples were analyzed using a fully automated urine analyzer. Among the samples, 194 were positive for urine protein, and 200 were negative for urine protein. Similarly, 219 were positive for leukocyte esterase, and 175 were negative for leukocyte esterase. Thirty-seven were positive for nitrite, and 357 were negative for nitrite (Table 3). Based on these data, the calculated results are as follows: for urine protein, the sensitivity was 52.44%, specificity was 51.60%, PPV was 22.10%, NPV was 80.50%, positive likelihood ratio (LR+) was 1.08, negative likelihood ratio (LR−) was 0.92, P_o was 55.94%, and the Kappa coefficient was 0.11. For leukocyte esterase, the sensitivity was 76.83%, specificity was 50.00%, PPV was 28.75%, NPV was 89.12%, LR+ was 1.54, LR− was 0.46, P_o was 55.66%, and the Kappa coefficient was 0.08. For nitrite, the sensitivity was 32.93%, specificity was 96.80%, PPV was 72.97%, NPV was 84.58%, LR+ was 10.29, LR− was 0.69, P_o was 83.53%, and the Kappa coefficient was 0.44 (Table 2).

Table 3. Comparison of urine routine indicators and traditional culture method (BACTEC) for urinary tract infection detection (n=394).

Urine indicators	BACTEC+	BACTEC−
Pro+	43	151
Pro−	39	161
LE+	63	156
LE−	19	156
NIT+	27	10
NIT−	55	302
UTCD+	74	213
UTCD−	8	99

BACTEC+, traditional urine culture found bacteria; BACTEC−, traditional urine culture found not bacteria; LE+, leukocyte esterase positive; LE−, leukocyte esterase negative; NIT+, nitrate test positive; NIT−, nitrate test negative; Pro+, protein positive; Pro−, protein negative; UTCD+, three indexes of urine routine combination for diagnosis positive; UTCD−, three indexes of urine routine combination for diagnosis negative.

When these three indexes of urine routine combination for diagnosis (UTCD), the results were as follows: sensitivity of 90.24%, specificity of 31.73%, PPV of 25.78%, NPV of 92.52%, LR+ of 1.32, LR− of 0.31, P_o of 43.93%, and a Kappa coefficient of 0.11.

Evaluation of HB&L system identification

Among the 79 samples that were positive in both HB&L system detection and traditional urine culture, the HB&L system’s pathogen identification results were as follows: for fungi, 5 out of 7 samples were correctly identified, with a success rate of 71.43%; for Gram-negative bacilli, 40 out of 42 samples were correctly identified, with a success rate of 95.24%; for Escherichia coli, 24 out of 25 samples were correctly identified; for Gram-positive cocci, 19 out of 25 samples were correctly identified, with a success rate of 76% (Table 4). Among the five cases of mixed infections, the HB&L system accurately identified both strains in two cases and one strain in three cases (Table 5).

Table 4. Organism wise comparison between traditional culture and HB&L (n=74).

Organisms	Total number	Correct identification from inoculated HB&L vials, n	Misidentification by pellet from HB&L vials		No identification or reported sterile by pellet from HB&L vials, n	Gram staining from HB&L vials
			Correct genus, n	Different genus, n		Correlation, n	Not correlation, n
Escherichia coli	25	24	0	0	1	25	0
Klebsiella pneumoniae	7	7	0	0	0	7	0
Klebsiella oxytoca	1	1	0	0	0	1	0
Enterobacter aerogenes	1	1	0	0	0	1	0
Klebsiella aerogenes	1	1	0	0	0	1	0
Morganella morganii	1	1	0	0	0	1	0
Citrobacter koseri	1	1	0	0	0	1	0
Proteus mirabilis	3	3	0	0	0	3	0
Enterobacter cloacae	2	1	0	1	0	2	0
Streptococcus agalactiae	6	4	0	0	2	6	0
Enterococcus faecium	6	6	0	0	0	6	0
Enterococcus faecalis	5	4	0	1	0	4	1
Staphylococcus aureus	2	2	0	0	0	2	0
Staphylococcus haemolyticus	3	2	0	1	0	3	0
Staphylococcus epidermidis	1	0	0	0	1	1	0
Streptococcus gallolyticus	1	0	0	0	1	1	0
Lactococcus garvieae	1	0	0	0	1	0	1
Candida glabrata	4	3	0	0	1	4	1
Candida albicans	1	0	0	0	1	0	1
Candida parapsilosis	1	1	0	0	0	1	0
Candida tropicalis	1	1	0	0	0	1	0

Table 5. Traditional culture of multibacteria compared with biointelligence of HB&L (n=5).

Traditional urine culture	HB&L
Proteus mirabilis/Escherichia coli	Escherichia coli
Candida glabrata/Escherichia coli	Escherichia coli
Proteus mirabilis/Escherichia coli	Proteus mirabilis/Escherichia coli
Streptococcus agalactiae/Escherichia coli	Escherichia coli
Klebsiella pneumoniae/Escherichia coli	Klebsiella pneumoniae/Escherichia coli

These results indicate that the HB&L system demonstrates high accuracy and reliability in the rapid diagnosis of UTIs, particularly in detecting Gram-negative bacilli.

Discussion

Prompt and accurate diagnosis of UTIs is crucial in clinical practice, especially with the rising threat of antibiotic resistance. This study evaluated the effectiveness of the HB&L system for the rapid diagnosis of UTIs and compared its performance with traditional urine culture methods.

The HB&L system demonstrated high sensitivity (89.77%) and specificity (96.88%). Its PPV was 88.76%, and its NPV was 97.19%, indicating that the HB&L system is reliable in identifying true positive and true negative UTI cases. These results are consistent with previous studies, which have also shown the system’s ability to quickly and accurately detect bacterial and fungal infections in urine samples (24,25). Furthermore, the high Kappa coefficient (0.8632) supports the strong concordance between the HB&L system and traditional culture methods, underscoring the system’s reliability, a finding also highlighted in Sharma et al. [2023], which further supports the robustness of our results (5).

This study also compared the performance of routine urinalysis indicators (urine protein, leukocyte esterase, and nitrite) with traditional culture methods. The sensitivity of routine urinalysis varied, with leukocyte esterase showing the highest sensitivity (76.83%). However, nitrite demonstrated significantly higher specificity (96.80%), suggesting that positive nitrite results could be a specific marker for UTI. Nonetheless, the overall diagnostic performance of routine urinalysis was inferior to the HB&L system, highlighting the latter’s superiority in rapid and accurate UTI diagnosis.

In modern surgical practice, particularly in the management of outpatient surgeries, preoperative precision testing for UTIs is of paramount importance. By accurately identifying and managing potential UTIs, preoperative urine cultures and sensitivity testing can significantly reduce the risk of postoperative infectious complications (26,27). This precise diagnostic approach not only ensures that patients are in optimal health before surgery but also enables personalized antibiotic prophylaxis strategies. This helps avoid the unnecessary use of broad-spectrum antibiotics, thereby reducing the emergence of resistant bacterial strains (28). Additionally, preoperative precision testing reduces postoperative hospital stays and readmission rates, which is particularly important for outpatient surgery patients who are discharged on the same day of their procedure (29). Overall, precise preoperative testing and management of UTIs are crucial for optimizing postoperative recovery, improving surgical success rates, and reducing healthcare costs (29).

The HB&L system offers several significant advantages over traditional urine culture. The HB&L system can provide results within 4.5 hours, whereas traditional culture methods typically require 24–48 hours. This rapid turnaround time is crucial for timely clinical decision-making and can improve patient outcomes by allowing for the prompt initiation of appropriate treatment (30). Rapid diagnosis not only reduces patient wait times but also mitigates the risk of potential complications from delayed treatment. The HB&L system shows high diagnostic accuracy and excellent concordance with traditional culture results, highlighting its reliability and accuracy in detecting UTIs (31,32). Compared to traditional methods, the HB&L system better identifies complex or multiple infections, enhancing diagnostic precision. Given the rapid and accurate diagnostic results provided by the HB&L system, clinicians can more precisely select antibiotic treatments, reducing the misuse of broad-spectrum antibiotics. This is particularly important in the context of increasing antibiotic resistance (33,34). In our clinical practice, the Department of Urology performed 7,500 inpatient surgeries and over 2,000 outpatient surgeries throughout 2023. Most midstream urine culture samples were from inpatients undergoing urological stone surgeries. The introduction of the HB&L system has effectively reduced surgery wait times and unnecessary antibiotic use. For outpatient day surgery patients, the rapid negative reports provided by the HB&L system significantly reduced unnecessary antibiotic use and surgery wait times. Among inpatients, the system effectively shortened hospital stays and decreased unnecessary antibiotic use, thereby reducing the risk of the emergence and spread of resistant bacterial strains. The automated nature of the HB&L system can alleviate the workload of laboratory staff and reduce human errors associated with manual culture methods. This efficiency can save costs for healthcare institutions and improve patient care (4,35). The introduction of automated systems can also enhance overall laboratory efficiency, ensuring that more patients receive timely diagnosis and treatment.

Despite the numerous advantages of the HB&L system, some limitations exist. Although the false positive and false negative rates are low, there is still a proportion of such results. These discrepancies may stem from sample quality, the presence of inhibitors, and inherent limitations of the optical density and biochemical reaction methods used by the system. For instance, two false negative cases showed clear inhibition zones on blood agar, indicating that the use of antibiotics could affect detection accuracy. Additionally, different pathogen types may respond differently to the HB&L system, potentially affecting diagnostic accuracy. While the HB&L system excels in detecting common UTI pathogens, further research is needed to evaluate its performance in identifying less common or atypical pathogens (36,37). For certain rare or emerging pathogens, traditional culture methods may still offer higher detection sensitivity and specificity. The cost of the HB&L system equipment and reagents is relatively high, which may hinder widespread adoption in resource-limited healthcare settings. Cost-effectiveness analysis is needed to ensure its economic viability in practical applications (38,39). Healthcare institutions must balance initial investment with long-term benefits when deciding whether to implement the system. The operation and maintenance of the HB&L system require specialized technical training, which may be challenging for some healthcare institutions. Ensuring that operators possess the necessary skills and knowledge is crucial to maximizing the system’s benefits.

Recently, after careful consideration and based on the promising results previously demonstrated by the HB&L system, we decided to implement it in clinical practice alongside traditional urine culture. After discussions with various clinical departments, we agreed on the following approach: All patients suspected of having a UTI and for whom a urine culture has been ordered will first undergo testing with the HB&L system. Within 4.5 hours, if the HB&L system shows a negative result, a negative urine culture report will be issued. For samples showing a positive result, they will proceed to re-plating, MALDI-TOF mass spectrometry identification, and further steps as necessary. This combined approach has significantly improved the efficiency of UTI detection at The First Affiliated Hospital of Guangzhou Medical University. The rapid results help avoid unnecessary delays in treatment initiation, particularly for patients with negative results from the HB&L system. Moreover, it streamlines the diagnostic process by narrowing down the samples that need further analysis, ultimately saving valuable time for both patients and healthcare professionals. Our approach has proven to be an effective strategy for rapid UTI diagnosis. The HB&L system provided fast diagnostic results, reducing treatment delays and enabling timely intervention. However, like previous studies, we emphasize the importance of using traditional culture methods for final confirmation, particularly in cases of mixed or rare infections. In our study, although the HB&L system showed promising results, we also performed MALDI-TOF mass spectrometry on the HB&L culture-positive results, where the positive result from the HB&L culture was directly analyzed by extracting the precipitate from the HB&L culture bottle. This differs from traditional methods, where bacterial colonies are grown on culture plates before mass spectrometry identification. While the MALDI-TOF MS results provided valuable insights, further validation with a larger sample size and multicenter studies is necessary to confirm its reliability and broader applicability. Future research should focus on expanding this approach to larger, multicenter settings to validate the generalizability of our findings. Although the integration of the HB&L system with traditional urine culture has shown great promise at The First Affiliated Hospital of Guangzhou Medical University, multicenter validation would ensure its effectiveness across different healthcare environments. Additionally, conducting cost-benefit analyses would help assess the economic feasibility of this combined approach, guiding other institutions in deciding whether to adopt this model. Finally, continued improvements to the HB&L system will be crucial, particularly in enhancing its sensitivity and specificity for identifying mixed infections or rare pathogens, ensuring its continued relevance in clinical settings.

Conclusions

In this study, we evaluated the diagnostic performance of the HB&L system for rapid UTI detection and compared it to traditional urine culture methods. Our findings demonstrate that the HB&L system provides accurate and fast diagnostic results, significantly reducing the diagnostic turnaround time from 24–48 hours to 4.5 hours. This improvement in diagnostic speed has the potential to enhance patient management and treatment outcomes, particularly in settings where rapid clinical decision-making is crucial.

While the HB&L system showed high sensitivity (89.77%) and specificity (96.88%), we recommend that it be used in conjunction with traditional culture methods for final confirmation, especially in cases of mixed or rare infections. Additionally, the integration of the HB&L system with mass spectrometry can further expedite pathogen identification, reducing diagnostic time and improving the accuracy of UTI diagnosis.

However, further multicenter studies with larger sample sizes are necessary to validate the generalizability of our results. The continued development of the HB&L system, particularly in its ability to detect mixed infections and rare pathogens, will be key to its broader clinical adoption.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University (approval number: ES-2023-229-01). Written informed consent was obtained from all participants prior to sample collection and testing.

Data Sharing Statement

Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-107/dss

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DOI: 10.21037/tau-2025-107