Download Urine testing guide for the educator

Developed as a teaching aid to accompany
Residents of Aged Care Homes &Urine Testing Protocol
Produced by the North East Valley Division of General Practice 2006
www.nevdgp.org.au
Residents of Aged Care Homes &Urine Testing Protocol
Guide for the Educator
Introduction
This Guide for the Educator has been developed to support the
Residents of Aged Care Homes & Urine Testing Protocol developed
by the North East Valley Division of General Practice.
Both the protocol & the Guide are informed by current evidence &
discussion with clinicians.
Why review an area of clinical management?
The common goal of GPs and Aged Care Home staff is to provide
medical care to residents that will improve their quality of life.
We rely on evidence from good quality clinical studies to guide our
practice (and new studies come out all the time).
These studies provide:
-
Evidence that the symptoms and signs we are using in our
clinical assessments are reliable
-
Evidence that the treatment we provide does more good
than harm.
A Clinical Dilemma
Accurate diagnosis of urinary tract infection in residents of aged
care facilities is not straightforward.
It requires a clinical judgment to be made based on a combination
of symptoms, signs & investigation.
The medical practitioner’s decision to treat may have to be made
without absolute certainty or proof.
Why review urine testing in particular?
Studies show high rates of Dipstick urinalysis & MSU testing occurs
in aged care homes leading to:
 Over-diagnosis of UTIs
 Unnecessary antibiotic use
 Medication related side effects
 Resistant organisms
 Excessive cost – ACH & GP staff time, pathology services,
medication
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KEY MESSAGES
Residents in aged care homes have high
rates of
ABNORMAL DIPSTICK AND MSU RESULTS
without infection necessarily being present


15-30% men 25-50% women in aged care homes have
abnormal urine test but no UTI
NB the rate of urine infections in the residential aged
care population IS higher than in the community, but
you cannot base the diagnosis of an infection on the
result of a urine test alone.
Diagnosis of a UTI in an aged care home
resident requires a combination of
RELIABLE CLINICAL SIGNS & SYMPTOMS
+
POSITIVE MSU

The interpretation of symptoms, signs and urine test
results in the aged care population is DIFFERENT from
that of the general community
There is NO role for Dipstick Urine test as a screening
test


ie Do not do a Dipstick test if the resident is not unwell
Think carefully before doing a dipstick test for an unwell
resident also – how will I interpret the result? Would an MSU
be better? Does this resident need a general clinical
assessment by the GP?
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When would you test for a UTI?
Notes
Only test for a UTI when reliable symptoms & signs are
present (these are symptoms & signs that have been shown
in studies to be more likely to indicate a UTI)
What symptoms are most likely to suggest a UTI?
 Dysuria
 Frequent passing of urine or urge to pass urine
 Bladder (low abdomen) or renal (loin) pain
 New onset or worsening of incontinence
What symptoms MAY occur in the resident with a UTI but
also occur as the result of other illness or infection?
 general malaise
 confusion
 nausea &/or vomiting
 haematuria
What signs are most likely to suggest a UTI?
 None are reliably associated with UTI
 In particular there is NO evidence to support cloudy urine or
smelly urine as reliable signs of UTI
What signs MAY occur in the resident with a UTI but also
occur as the result of other illness or infection?
 Confusion (change in mental state)
 Fever
 Suprapubic tenderness
 Loin tenderness
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What test should I choose?
Notes
Is Dipstick urinalysis reliable? -NO
What does a Positive dipstick mean?
Positive for Leucocytes (pyuria, white cells)
- can be produced by presence of bacteria, but may be
contamination
- is not always present when infection is present
- poor correlation with UTI
Positive for Nitrites
- Bacteria produce nitrites
- Some bacteria do not produce nitrites
- poor correlation with UTI
Bacteria may the cause of nitrites & leucocytes being present – but
does this mean there is an infection??
What does a Negative dipstick mean?
A negative dipstick result strongly suggests there is NO UTI
HOWEVER even a negative dipstick result is not 100% reliable- so
still suspect UTI if reliable symptoms present
Occasionally a GP may request a Dipstick test because a negative
result MAY carry some weight, but in general AVOID DOING
DIPSTICK TESTING
IF A UTI IS SUSPECTED AN MSU SHOULD BE PERFORMED
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How useful/reliable is an MSU?
Notes
How can you collect an MSU?
Is it possible in this population? rarely
Is a clean catch a suitable alternative? It may be all you can collect
but is not as reliable as an MSU
How do you interpret the MSU Micro & Culture result?
Positive MSU and no symptoms = bacteriuria, not infection
(observe)
Positive MSU and symptoms = supports diagnosis of UTI (treat)
Note: there is debate about what constitutes a positive culture
result in this population. Is it >108 or less? Does the presence of few
versus lots of white cells influence interpretation?
Negative MSU - not a UTI
Sensitivities: useful to help choose correct antibiotic
Contaminated urine: bugs & skin cells present
How do you decide whether to treat for a UTI or not?
Notes
The diagnosis of UTI ultimately rests with clinical
assessment. Clinical assessment means:
- exclusion of other causes
- collation of symptoms, signs & MSU result
Elderly patients with non-specific symptoms merit a full
clinical assessment (may include CXR, FBE etc)
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When to treat a UTI?
Depends on the clinical condition- if the resident is mildly unwell
then it may be appropriate to wait for the MSU result rather than
initiate treatment while it is still unclear whether a UTI is present or
not.
More on asymptomatic bacteriuria (MSU positive but no
symptoms of UTI)
Is there any advantage to treating asymptomatic
bacteriuria?
No evidence of prevention of future UTI
no evidence of survival benefit
no benefit in improving incontinence in resi care population
Patients with catheters
 Bacteria will be present in the urine of ALL residents with a
catheter
 Cloudy urine is NOT indicative of UTI in someone with a
catheter
 To collect a meaningful urine specimen from the resident with
an indwelling catheter (a CSU) it is necessary to change the
catheter first
 Treat with antibiotics only if clinical condition & CSU findings
suggest UTI
 In these patients loin pain & fever are significant indicators of
a UTI
An example of the potential impact of implementing this
“protocol”
At one aged care home the records of 45 residents treated for
“UTIs” were analysed. These UTIs were diagnosed primarily with the
use of dipstick testing. The analysis found that if the protocol (ie
using MSU results & clinical assessment) had been applied only two
residents would have been diagnosed as having a UTI.
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Prevention
Why do the elderly get UTIs?
Notes
Many aged related changes contribute to the vulnerability of the
elderly to UTIs
- Post menopausal changes -quality of the tissues around the
urethra poor
- Poor bladder emptying (structural changes, functional
changes)
- General immune suppression (eg poor nutrition, presence of
other illnesses, medications)
- Reduced mobility, dementia
What can we do to prevent Urine infections?
Notes






Toileting
Hygiene
Hydration
Nutrition
Bowel
Other
o Cranberry
o Antibiotics, surgery, medication, oestrogen
o Role of Ural etc
See next page for details
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UTI Prevention – Details
Toileting
Regular visits to the toilet to minimise time spent in dirty or wet pad
Hygiene: bacteria usually enter via the urethra
 Good management of incontinence of faeces
 Prevention of maceration of skin from dampness
Continence Pads
Proper continence pads are made to draw urine away from the skin
Regular changing of pads important as
 sitting in wet pad damages the skin & allows bacteria to enter
 faecal soiling carries bacteria that may cause a urine infection
When dealing with faecal incontinence that has left only a small smear of
faeces on the pad it may be appropriate to cover the area with a liner, but
in general consider changing the pad.
Washing
If there is extensive faecal soiling, use toilet paper to clean the resident
before washing. Use shower & soap (rather than sponging, as the water
gets dirty)
Do NOT use talcum powder
As it makes the pad less absorptive and holds bacteria near the skin
Hydration – essential (minimum of 1000ml/day unless fluid restrictions
in place)
Thirst drive is diminished in the elderly. Residents are often reliant on
staff for prompts to drink.
Most people need about 1.5 L of fluid per day but more if the weather is
hot, or if the resident has a fever
Less if fluid restriction order (eg residents with cardiac failure)
Nutrition – improves the body defences against all infections
Bowel – prevent & treat constipation
Other?
- Cranberry juice/capsules?
o Only proven to reduce rates of UTI in young women with
recurrent E coli UTIs
o Dose & frequency & form (juice or capsule) vary in all studies
o Consider the calories & sugar load of juice
- Daily antibiotics (if >3 Sx UTIs per year, but risk of resistance)
- Fix bladder dysfunction (structural, functional)
- Improve quality of tissues (oestrogen – some evidence helps stress
incontinence, less evidence for UTI prevention)
- urinary alkalinisers reduce symptoms (Ural, Atravescent, Citralite,
Citravescent, sodium bicarbonate, Uracol, Uricalm, Uricosal, UrociteK).
- They have no proven role in preventing UTIs & can interfere with
antibiotic effectiveness
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Illustration to explain Asymptomatic Bacteriuria
Male Urinary Tract
Female Urinary Tract
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