Author: Dr. Stephen Gore

In the spirit of antibiotic stewardship and limiting the side effects of said antibiotics, we took a critical look during our last Journal Club session at the utility of urinalyses, urine cultures and vague symptoms like confusion/altered mental state in diagnosing UTI. 

Of note, this discussion is looking at patients who DO NOT have classic symptoms like dysuria, frequency/urgency, suprapubic pain, CVA tenderness, etc.. and have no signs of serious systemic infection or instability to warrant empiric antibiotics (i.e., SEPSIS, fever, hypotension, tachycardia).  This journal club also highlighted the current Infectious Disease Society of America (IDSA) Guidelines.*

*We have used their guidelines this past year looking at backing off our Skin Soft Tissue Infection (cellulitis) treatment to NOT require MRSA coverage (why you’re seeing more use of cephalexin and cefazolin) and holding off starting antibiotics in the ED for osteomyelitis to allow for better culture data/possible bone biopsies to tailor coverage of this more chronic/simmering infection that does NOT benefit from early/empiric antibiotics. 

Testing (1..2..3..)

Urinalysis/dipstick 

Our go to in the ED as it’s all we have.  Takeaways – even with positive Leukocyte Esterase or Nitrite, the positive predictive value for these positive tests confirming a UTI are only around 50%.  This also brings up the utility of ‘cloudy, or “foul smelling” urine – although we’ve all seen this anecdotally, objectively they are not good at predicting actual infection. They are likely more reflective of hygiene, dehydratnoi, chronic illness and/or chronic colonization with bacteria. 

 Urine culture 

We classically look at >100k colonies  of a single organism as a concern for significant bacteriuria and not just skin contaminant. The main issue we discussed is the presence of bacteriuria CHRONICALLY in many of our patients. Particularly those in chronic long term care facilities; even on their best day if you culture their urine, it’ll grow bacteria so without a clinical picture for urinary infection we do not treat.  So the only patients who have NO symptoms but are growing bacteria in their urine on culture we currently treat are pregnant patients.  Everyone else we are being advised by the IDSA to not treat.

 —-So wow Gore, you’re saying UAs, and Urine Cx’s are useless. NO – this is just saying without a focal suspicion for urinary infection (urinary symptoms), we shouldn’t treat urine tests blindly or obtain these tests as a ‘routine’. This is GOOD, this means we have to be clinicians still, so we won’t be replaced by machines…yet.   

Discussion

Now onto the main discussion we had – what about the elderly patient with confusion/altered mental status/increased falls coming from SNF with an abnormal urinalysis?   The data out there is NOT robust but current literature does NOT support a relation between UTI and confusion or Falls (and yes we acknowledge many of us have anecdotal stories that disagree with this).  

So in an elderly patient who has AMS but otherwise benign workup (no fever/leukocytosis/unstable vitals), IDSA is advising we observe them for 24-48 hours to look for other causes of AMS before treating an abnormal urinalysis or urine culture if we have no other suspicion for UTI. The argument is that many of these patients get better either without any intervention, after some fluids for dehydration or cessation of some home medications that may be contributing to AMS.  The studies looked at any harm from waiting 24-48 hours to initiate abx and FOUND NONE.  It is not satisfying for the ED team to do nothing, but the concern for more harm than good from antibiotics is the crux of the argument (c diff, antibiotic resistance, etc).   And they did find early antibiotics PROLONGED HOSPITAL STAYS without perceived benefit.  

This will be a discussion with our hospitalist colleagues to make sure they’re on the same page as these IDSA guidelines as they may be frustrated as we’re not doing ‘anything’.  But on my end as the hospitalist**, this gives me 24 hours to see if fluids, time, a new environment (we know these patients come from less ideal places), or medication cessation is all they need. If you start antibiotics in the ED for the sake of ‘doing something’, I have no idea what made the patient better the next day and thus commits them to antibiotic regimens, prolonged hospital stays, etc. 

** Dr. Gore practices EM AND IM

Summary

Don’t treat an abnormal UA if the patient only has vague symptoms such as confusion or falls. You can send the urine studies, but let us observe them, expand the workup and see if time/fluids/med changes is all the patient needs. This can allow for quicker discharges from inpatient side, and less antibiotic harm.

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Articles Discussed

  • Mayne, S. Bowden, A. Sundvall, P. Gunnarsson, R. The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing- a systematic literature review. BMC Geriatr. 2019; 19(1): 32
  • Nicolle, L. Gupta, K. Bradley, S. Colgan, R. DeMuri, G. Drekonja, D. Eckert, L. Geerlings, S. Koeves, B. Hooten, T. Mehta, M. Knight, S. Saint, S. Schaeffer, A. Trautner, B. Wullt, B. Siemieniuk, R. Clinical Practice Guideline for the management of asytmptomatic bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clinical Infectious Disease. 2019; 68(10): e83-110
  • Petty, L. Vaughn, V. Flanders, S. Malani, A. Conlon, A. Kaye, K. Thyagarajan, R. Osterholzer, D. Nielson, D. Eschenauer, G. Bloemers, S. McLaughlin, E. Gandhi, T. Risk Factors and Outcomes Associated with treatment of asymptomatic bacteriuria in hospitalized patients. Jama Intern Med. 2019; E2-9.

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