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Discussion

Treating asymptomatic bacteriuria

I work in acute rehab, but I don't think that makes a big difference. That being said, I was taught that you do not check for a UA C&S if a patient is NOT having s/s of a UTI. However, every facility wants to check a urine everytime a patient is slightly more confused. I tried to discuss this with the psychiatrist the other day. She basically said that if she is not allowed to check a urine on her patients and treat them then she risks misdiagnosing them. I found a concensus paper from the Infectious disease society of america stating that it is not recommended to treat, but doesn't say about testing. However, I am meeting resistance at every turn. So the facility waits until I am not on call and gets my on call to give the order. They are all hospitalists so they do urines routinely and think nothing of it. I guess I just want to vent, but does anyone have any other resources or suggestions?

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    • Experts

    In the elderly, UTIs frequently cause confusion. Because many elderly can not obtain a "clean catch" specimen, obtaining a urine culture is much better.

    From UpToDate:

    DIAGNOSTIC TESTS

    Laboratory tests — A number of laboratory tests may be considered in the patient with delirium. However, the desire for diagnostic completeness can increase costs and possibly delay the prompt treatment of more obvious disorders. Targeted testing is appropriate in most instances.

    ●Serum electrolytes, creatinine, glucose, calcium, complete blood count, and urinalysis and urine culture are reasonable for most patients when a cause is not immediately obvious.

    ●Drug levels should be ordered where appropriate. However, clinicians must be aware that delirium can occur even with "therapeutic" levels of such agents as digoxin, lithium, or quinidine.

    ●Toxic screen of blood and urine should be obtained from patients with acute delirium or confusion when a cause is not immediately obvious. Again, clinicians must be aware that some common drugs (eg, risperidone) are not assessed in routine laboratory screens. Therefore, overdose of these drugs cannot be excluded by negative results from a toxic screen.

    ●Blood gas determination is often helpful. In hyperventilating patients, respiratory alkalosis is most commonly due to early sepsis, hepatic failure, early salicylate intoxication, or cardiopulmonary causes. A metabolic acidosis usually reflects uremia, diabetic ketoacidosis, lactic acidosis, late phases of sepsis or salicylate intoxication, or toxins including methanol and ethylene glycol. A chest x-ray is usually performed.

    ●Further testing, such as liver function tests, should be based upon the history and clinical examination. A report of slow cognitive decline over several months, for example, will increase the importance of evaluating thyroid function and vitamin B12 levels.

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    • Author

    Delerium, yes. Not slight confusion. That's the problem. In the ER they do it all the time. I feel like it's throw it at the wall and see what sticks. Im having a hard time getting past that training. Confusion = UTI

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    The reason you see people ordering it is because its a cheap and effective ruleout. No thousand dollar test for a simple rule out. The slightest whiff of infection in the elderly can be a huge impact or a small one, everyone responds differently.

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    My patient population is primarily over 65 with many in their 90's. We automatically dip and treat for UTI with a number of s/s, such as any altered loc off baseline, even forgetfulness. Primarily because many of my pt's live alone and the risk for complications such as falls, medication errors, ect... is high. I'm also trying to prevent IC, which I see often as well. This may not be the best practice, but I'm confident that it's better than not treating.

    Mike

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    • Experts

    The other issue with the elderly is that since many can not obtain a clean catch, please order a urine culture if you choose to treat a UA dip. That way, if it doesn't grow anything treatable, you can stop the antibiotic, thus preventing (hopefully) c-dif - another concern in our over-antibioticized world (new word I just made up - lol)

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    The other issue with the elderly is that since many can not obtain a clean catch, please order a urine culture if you choose to treat a UA dip. That way, if it doesn't grow anything treatable, you can stop the antibiotic, thus preventing (hopefully) c-dif - another concern in our over-antibioticized world (new word I just made up - lol)

    Your comment raises a question. Does the risk of c-diff outweigh the benefit of quicker intervention?

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    • Experts

    If you are treating only until the urine culture returns (48-72 hours) the risk of cdif is negligible.

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    The other issue with the elderly is that since many can not obtain a clean catch, please order a urine culture if you choose to treat a UA dip. That way, if it doesn't grow anything treatable, you can stop the antibiotic, thus preventing (hopefully) c-dif - another concern in our over-antibioticized world (new word I just made up - lol)

    The elderly patients in the ER were always straight cathed for a UA. Toss the headers and footers and take it right from the center stream. I agree a urine culture is a good tool, at our facility regardless of how the urine was collected, if bacteria shows up an automatic C&S gets added.

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    • Experts

    Yes and that is what we did in the ER also. However, OP works in rehab where straight cath'ing is not always possible. I work outpt where cath'ing is not possible unless I send pt to hospital (and then they love it when I send my bilateral lower extremity amputees to be straight cath'd when they are only moved by Hoyer)....ugh!

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    Well that's the problem. A straight cath can be done anywhere, I can tell some stories from when I used to work home health. The facility needs to get some kits, anyone can do a straight cath.

    Mike

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    • Experts

    Not in a dialysis clinic. Lol.

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    I found a concensus paper from the Infectious disease society of america stating that it is not recommended to treat, but doesn't say about testing.

    What I remember about this is that you generally don't treat it---unless the patient is pregnant or pre-op for invasive uro/gyn type procedures. I once had a discussion about a slightly different issue with an infectious disease doctor who told me that, when it comes to old people and suspected UTIs, don't treat empirically with any antibiotics---wait for a positive urine. And the powers that be still don't recommend treating if the count is less than 100,000. They might have new evidence based guidelines now. I don't know. The textbooks and medical journals used to all say that you should do a culture since it is still the gold standard to rule out, but the bean counters don't like it when you order cultures for everybody because it is cost more than a UA with micro, so I usually order the latter first.

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