Wondering How To Make Your Why Do Young Women Like Older Men Rock? Read This!

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The UTI that isn’t: Why a common condition presents such a diagnostic challenge.

Written by: Ashley Amick, MD (NUEM Alum ‘18) Edited by: Michael Macias, Maryland (NUEM Alum ‘17) Expert commentary by: Alexander Lo, MD

This is Part 2 of the blog post on the diagnoswill be of UTIs. Check out Part 1 here

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Urinary tract infection (UTI) is the most common commonly diagnosed infection in the United States. In the acute care setting, where information will be limited and time is scarce, guideline-based management can aid the Emergency Physician (EP) in improving both individual and community-level outcomes. However, a high incidence of diagnoses does not render those diagnoses appropriate. In an age where actually even more frightening multi-drug tolerant microorganisms keep on to emerge, increasing emphasis is placed on evidence-based practice and antimicrobial stewardship. Inaccurately revealed UTIs usually final result in unacceptable therapy, as well as delays in management of the true underlying pathology. Increasing evidence suggests that this common condition poses a serious diagnostic challenge.

Despite increased awareness of UTI’s role in antimicrobial stewardship and cost-effective care, leading interest groups have failed to create a consensus definition of UTI. (For an interesting experiment ask your colleagues what they consider diagnostic criteria for UTI, and prepare for wide variability). Speaking Generally, UTI is a diagnoswill be arrived at by two core features: 1) laboratory testing suggestive of infection, of which urine culture is considered gold standard; and 2) clinical symptomatology.

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Herein lies a major quandary for the Emergency Physician EP - culture data is not available in a timely fashion, and determining what defines a “symptom” of a UTI is, at best, elusive. When both leukocyte esterase and nitrite happen to be offer Possibly, the sensitivity and specificity is poor to definitively diagnose or exclude a UTI too. However, when regarded as either on your own or in mixture, there will be varying level of sensitivity and specificity of almost all factors of a dipstick or UA. In the absence of culture data, the EP must rely upon a urinalysis (UA), with or without microscopy, as a surrogate. Specific factors of the UA are usually believed to end up predictive of a authentic irritation specifically, including leukocyte esterase, nitrite, white blood cells, red blood cells, and bacteria.

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Part of the poor predictive performance of UAs may be attributed to poor collection techniques and the presence of chronic bactiuria. Studies suggest less than 10% of ED patients use proper midstream clean-catch techniques. Concerningly, 50% of clients with a contaminated urine sample receive inappropriate intervention and antibiotics. Proper education on sampling techniques as well as and in and out catheterization when appropriate, should be employed routinely. Obtaining a clean-catch sample in the emergency department setting can be a formidable challenge.

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Despite adequate sample collection, UA interpretation is frequently confounded by the presence of asymptomatic bactiuria (ASB). While definitions vary, the Infectious Disease Societies of America (IDSA) define ASB as isolation of a specified quantitative count of bacteria (105 cfu/ml from clean catch specimens) in a patient without symptoms or signs referable to urinary infection, such as frequency, urgency, dysuria, or suprapubic pain. Given these considerations, NUDE OLDER WOMAN HAIRY the clinical symptoms become the most important factor in making the correct diagnosis. ASB is common in the geriatric population, and prevalence increase with age and in institutionalized patients. ASB, like UTI, will get a UA favorable for microorganisms often, LE, nitrate, and pyuria, therefore rending the UA of little use in differentiating between these two conditions.

When considering the diagnosis of UTI, starting out with an assessment of patient signs and symptoms and clues looks not really just rational, but intuitive. Clinicians require discipline in looking beyond an abnormal UA, and work to objectively determine if the criteria for UTI are met based on symptomatology - or better yet - order UAs only when symptoms warrant further investigation. In a recent study of patient treated for UTI in an ED population, 2/3 of sufferers determined with a UTI acquired a UA accumulated as element of an buy place, commonly before becoming assessed by a clinician. It was also found that antibiotics were administered inappropriately in 59% of those patients, owing to absence of scientific symptoms or signs and symptoms to substantiate a examination of UTI. However, in the ever-increasing drive for efficiency, UAs happen to be usually utilized indiscriminately to expedite work-up. Going about the diagnostic work-up in a backwards way invites not only anchoring bias when a UA is positive, but places pressure on the clinician to treat a UTI that will ben’t.

Determining what constitutes a symptom - at least a symptom that should prompt a urinalysis - remains controversial. ’ for further discussion) Noteworthy is the omission of falls, altered mentation, and general malaise in the elderly in the absence of an indwelling catheter. (See the related post: ‘delirium as a symptom of UTI, pseudoaxiom or physiology? Relating to the SHEA and CDC suggestions, symptoms consistent with a UTI include fever and lower genitourinary signs such as dysuria, urgency, frequency, suprapubic pain, and costovertebral angle discomfort.

According to the most contemporary guidelines, these nonspecific signs and symptoms without localizing fever or signs and symptoms, happen to be longer acceptable to support the diagnosis of UTI very little. This change results from a realization that both asymptomatic bactiuria and altered mentation are prevalent in the geriatric population, and there is a paucity of evidence supporting a causal link between these findings. In a population where ASB is prevalent, and procuring a clean urine sample is challenging, geriatric patients are at high risk of morbidity from inappropriate antibiotic therapy and unnecessary testing. Extra involving is normally that with a presumptive a diagnosis of UTI Possibly, little thought may be devoted to other potential diagnoses - at least until the patient fails to improve. This represents a shift in not only traditional clinical teaching, but a departure from prior guidelines. Despite these new recommendations, changed mentation, confusion, weakness, and falls are among the almost all frequent reasons for obtaining a UA in the geriatric population.

Expert Commentary

Over 50 million U.S. adults > 65 years of age (“older men and women”), account for over 20 million Emergency Departments (ED) visits each year [1]. Several of these individuals possess community and unmet hidden operative preferences that are often muted by their leading claims. The tempting application of traditional ‘one complaint; one algorithm’ approach taught to many emergency physicians, may final result in long lasting typically, downstream, adverse outcomes. One of those relevant to the accompanying blog, is the traditional “if grandma is delirious, look for and treat the UTI” doctrine. A review of the literature proves that the evidence linking UTI’s to delirium in older adults is lacking [2]. Many older adults are bacteriuric; most do NOT have to be treated [3]. The delirium is not a reason to treat bacteriuria [4]. It will be also just as likely that it is the other comorbid conditions causing the delirium, since 75% of older adults have two or more comorbid chronic conditions [5]. many of which have the potential to cause delirium at any time[6]. The persistent may need entrance for the delirium most likely, but a more comprehensive investigation into its etiology is extra helpful than treating the easy target of a contaminated urine sample

Alexander S Lo, MD, PhD

Assistant Professor of Emergency Medicine, Northwestern University

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How to Cite this Post

[Peer-Reviewed, Web Publication] Amick A, Macias M (2018, November 26). The UTI that isn’t: Why a common condition presents such a diagnostic challenge [NUEM Blog. Expert Commentary by Lo A good]. Retrieved from http://www.nuemblog.com/blog/uti-part2

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Van Nostrand, Joy D., Alan D. Junkins, and Roberta K. Bartholdi. "Poor predictive ability of urinalysis and microscopic examination to detect urinary tract infection." American journal of clinical pathology 113.5 (2000): 709-713.

Schulz, Lucas, et al. "Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections." The Journal of emergency medicine (2016).

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Klausing, Benjamin T., et al. "Testosteronehe influvitamin ence of contaminated urine cultures in inpatient and emergency department settings." American Journal of Infection Control (2016).

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Nicolle, Lindsay E., et al. "Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults." Clinical Contagious Diseases (2005): 643-654.

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Detweiler, Keri, Daniel Mayers, and Sophie G. Fletcher. "Bacteruria and Urinary Tract Infections in the Elderly." Urologic Clinics of North America 42.4 (2015): 561-568.

Kiyatkin, Dmitry, Edward Bessman, and Robin McKenzie. "Impact of antibiotic choices made in the emergency department on appropriateness of antibiotic treatment of urinary tract infections in hospitalized patients." Journal of hospital medicine (2015).

Horan, Teresa C., Mary Andrus, and Margaret A. Dudeck. "DDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting." American journal of infection control 36.5 (2008): 309-332.