A Pee Problem
Author: Sarah Learmonth @EM_Ayr
09/05/2018
Does everyone else have this or am I just getting old?
I’m slightly amazed we don’t keep dipsticks in the staff toilets in the Emergency Department because everyone else that so much as thinks about having a pee is getting their urine checked. (Lets not start with them in the staff toilets – dipstick tests used in isolation would overtreat 47% and undertreat 13%)
The Youngsters
The 24 year old girl with a 1 day history of frequency, urgency and dysuria. What gets done? A urinalysis. Then because it’s positive an MSU (which isn’t an MSU really is it?) is sent. Maybe then we’ll think about treating her.
Lets break that one down. Young woman. 3 symptoms of UTI. We should be excluding upper UTI (loin pain, flank tenderness, fever, rigors, systemic inflammatory response) and asking about vaginal itch or discharge. And if we do that and she has neither then check if this is a new presentation and if so just treat her. No urinalylsis. No MSU.
Maybe she doesn’t have frequency. OK in that case (2 symptoms of UTI) we CAN use dipstick to guide treatment options – positive then treat, negative then discuss the benefits of empirical treatment with the patient.
What’s the harm you say? (ask microbiology who are drowning in pee)
A 53 year old woman with abdominal cramps, decreased oral intake, vomiting, decreased urine output. Gets a urinalysis done. It’s positive. Treated for UTI. MSU sent. No growth. Hmmm..... No symptoms or signs of UTI. No reason for dipstick. But once it’s done and positive people feel they have to act on it.
Will I throw in the spanner of a negative culture not ruling out UTI in symptomatic patients here? No? OK then....
Not a spanner but why does she have leucocytes in her urine then? It could just be dehydration. Being elderly can do it to. AKI, STI, appendicitis and diverticulitis too.
And The Oldies...
A 93 year old woman, simple fall (yes, really). No, seriously, she lives in a residential home and staff saw her trip on a visitors dog. Goes to the toilet in the ED - Nursing notes “went to toilet, passed urine, dipstick +ve, MSU sent.” 3 days later it’s back. E.coli. Well it’s good we picked that up yes? Eh. Well. Maybe if it wasn’t the case that bacteriuria does not indicate infection in the absence of signs and symptoms. Asymptomatic bacteriuria does not need treatment, has a >50% incidence in women living in care homes and the number needed to harm from treating asymptomatic bacteriuria?.... Is 3.
ALSO – we should not be using dipstick to diagnose UTI in elderly (>65 years) patients. Assess for symptoms/signs robustly, (I said robustly – smelly urine does not mean a thing) send an MSU and treat. Bear in mind constipation is as likely a cause for new confusion as UTI is and if anyone is doing as many PRs as they send MSUs? Well, I might choose not to shake your hand.
What About The Men?
What about the men? Signs and Symptoms = MSU. No dipsticks here either.
So What Can We Do?
I’ve been going on about this for months. We’ve changed our forms for recording urinalysis findings so that symptoms can be recorded there too. We added a box for what was done with the specimen which includes “left with patient” so if staff can’t help themselves then at least MSUs are only sent after a clinician has a think about it. We’ve audited the management of young women with possible UTIs (surprisingly compliant with SIGN guidelines!) I’ve tried and failed to figure out a way to audit to see if any of these changes have made a difference but I’m looking for a negative in a pile of mostly elderly so that’s not really worked (and what I have found tells me we are still dipsticking when we should not and treating the results).
Then I went to the CPD conference and the queen of pee, Linda Dykes from Bangor, said she has been doing all that and more and all the QIPs in the world have not stopped a thing. Surprisingly this was a relief. There is not a golden ticket solution to this problem. (if someone has actually found one please let me know).
So maybe this is one final rant about pee. I’ll keep reminding people. I’ll review case notes of all the MSU results that come back to me and feedback on the inappropriate use. Do the same with the routine urinalysis. Maybe one day all this will result in a change.
Maybe....
Links
Bangor COTE site- https://www.cotebangor.org/
Linda Dykes twitter @mmbangor
SIGN 88 - http://www.sign.ac.uk/sign-88-management-of-suspected-bacterial-urinary-tract-infection-in-adults.html/