Further to a recent post regarding the reliability of dipsticks in detecting urinary tract infections, here we discuss asymptomatic bacteriuria and uncomplicated, acute, lower urinary tract infections – specifically the importance of conducting thorough assessment so as to ensure the best course of treatment.
“Mrs X, a frail, 85-year-old woman, is a “little agitated” and “just not herself today.” After assessing Mrs X, her nurse decides to perform a dipstick test on a urine sample, which is found to be positive for nitrite and leukocyte esterase. Mrs X’s physician is contacted and told of the positive dipstick results. The physician orders a urine culture and begins empiric antibiotic therapy.” (van Buul et.al., 2018)
This scenario will sound familiar to many nurses, in fact, it makes you wonder who has been lurking around the corridors listening to nurses’ conversations ?
The direct quote is from a paper by a consortium of geriatric medicine and infectious disease specialists, all internationally renowned and respected, including from Australia.
This is the follow-on blog as mentioned in the previously published Are urine dipsticks reliable for diagnosing UTI?
The discussion here is related to asymptomatic bacteriuria and uncomplicated, acute, lower urinary tract infections, with a focus on elderly persons but excluding those with a urinary catheter.
Symptomatic or Asymptomatic
In the literature, urinary tract infections (bacteriuria) are generally defined as either symptomatic or asymptomatic.
An uncomplicated bacteriuria is an infection that occurs where there are no structural or functional abnormalities of the urinary tract system. (Nicolle, 2009).
A symptomatic urinary tract infection is the presence of bacteriuria (≥105 cfu/mL) accompanied by clinical signs and symptoms related to the urinary system, such as dysuria, frequency, development of or increased incontinence, suprapubic pain, or pain over the kidney area (costovertebral region). (Godbole et al, 2020; Juthani-Mehta, 2009; Nicolle, 2009). Antibiotic treatment is recommended. Two points worth noting is the urine specimen must be a ‘clean catch’; the count for men ‘clean catch’, with appropriate symptoms, maybe 103 cfu/mL (Nicole, 2016). This is all straightforward and known to nurses.
Asymptomatic bacteriuria (ASB) is less straightforward and according to most of the literature, there is no gold standard for diagnosis. It is documented in the papers I have read that treatment of asymptomatic has resulted in the ‘abuse’ of antibiotics and the increase of antibiotic-resistant bacteria in residential care.
At present asymptomatic bacteriuria is the presence of one (1) or more species of bacteria growing in the urine at specified quantitative counts (≥105 colony-forming units cfu/mL or ≥108 cfu/L), with or without the presence of pyuria, in the absence of any new clinical signs or symptoms attributable to a urinary tract infection.
Not necessarily “symptomatic of a urinary infection”
Regardless of what many nurses believe Nicolle (2009) stated that any change in the character of urine; behaviours or mental status, even in the presence of bacteriuria plus pyuria, without genitourinary signs or symptoms, or new genitourinary signs and symptoms, should not be immediately regarded as a “symptomatic of a urinary infection” requiring treatment with antibiotics. This is further supported by Jump et al. (2016) and Biggell et al., (2019).
We all recognise that nurses have a significant role in the business of Antibiotic Stewardship but on occasion, we do not leave evidence of a thorough assessment, only the result of a urine test. Has a medical diagnosis been made?
Details of a full and thorough assessment are necessary. Words such as “a little agitated”; “not herself”, and I have added “more confused” can not be measured. But as many of you appreciate, they trigger a urine test and often a prescription for antibiotics.
Here is a free copy of the paper by Biggel et al. (2019).
Disclaimer
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