Urinalyses

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watermanMD

watermanMD

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UA is part of too many nursing-driven protocols at my shop. Cough and fatigue? ****in’ urinalysis. Epigastric abdominal pain? ****in’ urinalysis. Even some UA’s on chest pain’ers.

Sometimes find myself unsure what to do with some of theses results—e.g. a positive nitrate or large leukocyte esterase + WBCs in patients with zero symptoms whatsoever. I know the sensitivity and specificity numbers (curious if those were derived from a symptomatic patient pop, or purely subsequent positive urine culture).

Just curious what you all are doing. I realize there’s, of course, nuance to this question but does anyone have a threshold for empirically treating – say a positive nitrate and any abdominal pain? How about an old patient with equivocal UA and vague, generalized malaise/ fatigue? What do you do with a disgusting looking urine in a patient without symptoms? I feel like most of my attendings in residency suggested I treat (cya mindset).

On a similar note, what are you giving for asymptomatic bactiuria in pregnancy?
 
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Are you ordering these UAs or just getting stuck with triage PLPs cr**py shotgun orders? If the former, stop ordering them on patients, obviously. If the latter, tell them to stop ordering them on patient unless they are septic/abd pain/urinary symptoms.

There, problem fixed. Just because something is in an order set doesn’t mean you can’t remove it from the order set.

As for what to do when you get stuck with an abnormal result in an otherwise asymptomatic patient. Unless it is a slam dunk >100 WBCs, +nitrites, >100k bacteria, I’m going to ignore it and just send it for culture and they can call them back if it grows out anything. More nebulous results with nebulous symptoms (mild dizziness/weakness/fatigue), sure, I’ll probably treat.
 
Zebra Hunter said:
There, problem fixed. Just because something is in an order set doesn’t mean you can’t remove it from the order set.
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This.
We don't have UAs in our order sets except for, you know, the urinary symptoms one. I can't imagine that nursing is going to fight you on this one either. It isn't like they're chomping at the bit to go collect a UA. Have it removed from the orderset.
 
I get urines on everyone except the people I have them ordered for

It's some kind of cosmic thing where people can sit in the lobby for flank pain for six hours and have labs and CT resulted but no one ever gets a urine.

But toe pain x6 months? Urine result arrives in room before patient. F me.
 
Pregnancy - Keflex, unless there's a reason not to.

Young and healthy but no dysuria - only if UA is a slam dunk UTI

Old and demented with vague complaints- if UA looks even kind of positive

For most patients when UA is vaguely positive I will go back and ask more in depth urine questions -- pain with urination, suprapubic discomfort, feeling like they aren't emptying fully, polyuria, foul urine smell -- those usually get antibiotics. Otherwise, I will wait for culture.
 
AlmostAnMD said:
I get urines on everyone except the people I have them ordered for

It's some kind of cosmic thing where people can sit in the lobby for flank pain for six hours and have labs and CT resulted but no one ever gets a urine.

But toe pain x6 months? Urine result arrives in room before patient. F me
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brabbit2222 said:
Pregnancy - Keflex, unless there's a reason not to.

Young and healthy but no dysuria - only if UA is a slam dunk UTI

Old and demented with vague complaints- if UA looks even kind of positive

For most patients when UA is vaguely positive I will go back and ask more in depth urine questions -- pain with urination, suprapubic discomfort, feeling like they aren't emptying fully, polyuria, foul urine smell -- those usually get antibiotics. Otherwise, I will wait for culture.
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This is what I do.
 
My favorite is when the young males come back positive and it’s like bro, where you been sticking that thing, huh?
 
RustedFox said:
No love for macrobid?
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Macrobid is absolute dog$hit. It causes old people to get dizzy or act goofy. It’s only bacteriostatic, not cidal, and should never be used for ascending infections. I hate it and I commonly see old people for nonspecific complaints and it’s not the uti, it’s that they were placed on macrobid a few days earlier. It’s on the BEERs list for meds you shouldn’t use on old people. /endrant
 
Pretty sure that the correct answer for asymptomatic bacteriuria in pregnancy is macrobid.

If urine looks bad and patient has no symptoms I let it reflex to culture and document as such. No sense in treating colonization.
 
Tenk said:
Macrobid is absolute dog$hit. It causes old people to get dizzy or act goofy. It’s only bacteriostatic, not cidal, and should never be used for ascending infections. I hate it and I commonly see old people for nonspecific complaints and it’s not the uti, it’s that they were placed on macrobid a few days earlier. It’s on the BEERs list for meds you shouldn’t use on old people. /endrant
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Didn't know it was on the list. Thanks
 
Jabbed said:
Pretty sure that the correct answer for asymptomatic bacteriuria in pregnancy is macrobid.

If urine looks bad and patient has no symptoms I let it reflex to culture and document as such. No sense in treating colonization.
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There was some recent study on macrobid causing some random issues with pregnancy, I think it was third trimester. As I’m too lazy to look it up, I tend to just avoid macrobid for the reasons tenk mentioned above. It also doesn’t penetrate the prostrate at all, just concentrates in the bladder. So it’s literally only good if they have a simple cystitis. If they have any other systemic symptoms, I would guess they could have some slight ureteral involvement and then macrobid is completely worthless as it won’t penetrate the tissue at all. I just use cephalexin or cefpodoxime or cefdinir. Bactrim for non elderly/non renal patients with anaphylactic pcn/cephalosporin allergies. Cipro or levaquin on occasion depending on prior cultures, or fosfomycin in certain circumstances, usually talking with pharmacy for that.
 
So, based on most of the above, I take it that I'm the only EM doc in the world who believes in asymptomatic bacteriuria? This would fit w/ my real life experience...

I love it when I see a + UA and document that clinically, it would represent asymptomatic bacteriuria and thus not merit treatment, but b/c there is an automatic reflex culture, invariably the patient gets called by f/u nurse and put on abx 2 days later.
 
turkeyjerky said:
So, based on most of the above, I take it that I'm the only EM doc in the world who believes in asymptomatic bacteriuria? This would fit w/ my real life experience...

I love it when I see a + UA and document that clinically, it would represent asymptomatic bacteriuria and thus not merit treatment, but b/c there is an automatic reflex culture, invariably the patient gets called by f/u nurse and put on abx 2 days later.
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Yeah on the occasion I get a UA I didn’t want that is ambiguous…

Hi, Patient do you have UTI symptoms you didn’t mention?!

If yes, treat (keflex)
If no, I get to write I think the patient has, at worst, asymptomatic bacteriuria and EBM suggests against treating.

No biggie, not risky, makes you look very reasonable under some odd retrospective review…
 
Janders said:
Yeah on the occasion I get a UA I didn’t want that is ambiguous…

Hi, Patient do you have UTI symptoms you didn’t mention?!

If yes, treat (keflex)
If no, I get to write I think the patient has, at worst, asymptomatic bacteriuria and EBM suggests against treating.

No biggie, not risky, makes you look very reasonable under some odd retrospective review…
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Exactly what I do. Hard in old people though. I've seen some IM people suggest using PCT values as a decision point on administering vs deferring abx, or just observing them off abx if getting admitted anyway (although hard to do nowadays when every artifactual RR of 26 triggers blood cultures, a lactate and an automatic referral to QI)
 
I see a lot of equivocal UAs that others call UTIs. I rarely treat asymptomatic bacteruria. I send more concerning UAs for culture and ignore the rest.

I stopped always treating equivocal UAs in pregnant women as it seems our local OBs also don’t treat. I do send them for culture and if positive think they should probably be treated.

Nitrite positive makes me think twice. Associated obstructing stone also has my attention.

Elderly patient who isn’t a reliable historian is hard to call asymptomatic.

Cephalexin is my go to. Prolonged courses and more frequent dosing for pyelo. During my training I took care of a girl in her 20s who died from SJS due to Bactrim and it forever scared me. I know it’s rare and not just due to Bactrim, but that case stuck with me. Cipro has high rates of resistance. Macrobid not good for elderly, poor renal function or pyelo.
 
Mount Asclepius said:
I see a lot of equivocal UAs that others call UTIs. I rarely treat asymptomatic bacteruria. I send more concerning UAs for culture and ignore the rest.

I stopped always treating equivocal UAs in pregnant women as it seems our local OBs also don’t treat. I do send them for culture and if positive think they should probably be treated.

Nitrite positive makes me think twice. Associated obstructing stone also has my attention.

Elderly patient who isn’t a reliable historian is hard to call asymptomatic.

Cephalexin is my go to. Prolonged courses and more frequent dosing for pyelo. During my training I took care of a girl in her 20s who died from SJS due to Bactrim and it forever scared me. I know it’s rare and not just due to Bactrim, but that case stuck with me. Cipro has high rates of resistance. Macrobid not good for elderly, poor renal function or pyelo.
Click to expand...

I had a patient come back with anaphylaxis from bactrim after I gave it and discharged him.
 
Macrobid for healthy young people with no concern for pyelo.

Keflex for the same but pregnant. Also for daily use in recurrent UTIs, but I don't expect that's something y'all would mess with.

2nd gen (ceftin being my go to) for old people or if maybe pyelo.

3rd gen (cefdinir usually) for definite pyelo.

Never cipro or bactrim unless patient has allergies to everything else.
 
In a generally healthy patient If they have no symptoms, I do not treat. I do not send a culture. Even if culture positive, who cares? It's asymptomatic. Even if generally unhealthy, I still need something to suggest actual infection to make me treat it.
 
Apollyon said:
Don't forget that quinolones can cause delirium in the elderly, and, the older, the more likely, and delirium has a 25% mortality rate. So, don't reflexively go for the Cipro or Levaquin.
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Does simple flouroquinolone associated delirium really have a 25% mortality rate? I find that a stretch. While I also typically avoid the class, I think the pendulum as swung a little bit to far against FQs.

carbonizedeyesockets said:
In a generally healthy patient If they have no symptoms, I do not treat. I do not send a culture. Even if culture positive, who cares? It's asymptomatic. Even if generally unhealthy, I still need something to suggest actual infection to make me treat it.
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Exactly. It's such backward thinking.

Also, guys, by the way. If a patient has an STI but a +UA and you feel the need to cover both, doxy is broad spectrum and does penetrate the urinary system...
 
I do not treat asymptomatic bacteriuria (unless pregnant) or pyuria. I do not send urine culture for asymptomatic pyuria. A lot of the APPs in our group does, and the pharmacist who has to follow the urine culture will come to me and say "this patient's urine culture is positie, but they had no symptoms documented. Recommendation is not to treat" and I go "I agree".

I also feel we overtreat asymptomatic pyuria espeically in the elderly demented population where every time they get a little confused, "Its always a UTI" until the only thing they grow is ESBL and have to be hospitalized for their asympatomic ESBL colonization for IV antibiotics. And ID has to step in and tell people to knock it off but it's too late.
 
turkeyjerky said:
Does simple flouroquinolone associated delirium really have a 25% mortality rate? I find that a stretch. While I also typically avoid the class, I think the pendulum as swung a little bit to far against FQs.
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It's what I was taught, so, I might be showing my age. Maybe an IM friend will support or deny my statement.
 
texasmed7 said:
Reading U/A is an example of a thing in medicine that truly is an art form so there is no 100% right or wrong having said that here is a simple approach that most experts aren't going to argue with so it's nice to have logic behind the approach.

Caveat this is mostly for the soft calls you're referring to!

You need what is called the TRI-fecta of infectious markers to feel good about treating a soft call U/A without symptoms and still not be wrong

1. +Esterase and/or Nitrites
2. + WBC
3. + Bacteria

*** ADD few epithelial cells to signify clean sample if you want but it's not needed but mention if you're proving a point when questioned whether that's a UTI by people that don't know how to read U/A's either as few truly do.

I just treat all trifectas as you're essentially not wrong for doing so, you don't need the trifecta if you have massive amounts of 1 or 2 infectious markers with symptoms of course or a multitude of other art readings of the UA but for soft calls something like +1 with few bacteria and few wbc's is the trifecta of U/A infectious markers hope that helps!
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Sounds like an overconfident IM or Uro intern. This is like the PGY1 version of a nurse saying the urine looks cloudy.

Broad body of literature suggests that pyuria, even when quite marked, does not signify a true UTI.

Man up, strap on your balls, and don't just do something, Stand There!
 
Probably the biggest crutch in EM. We joke about NPPs and the Zpak and steroid regimen, but I feel the same with a lot of EM docs and UAs. I almost never treat. Guess I shouldn't be surprised so many of you do on here. Unless it's pediatric, pregnant, or old (with very convincing UA) then they need real symptoms or no treatment. Most of the time these should not even been sent.

I try to cancel as many triage UAs as possible because it's pointless to even get the results on most patients. And "abdominal pain" is not a reason. There's likely a population variance. I would say 85% of the UAs at my ED are positive and looking at our patient population it's not surprising. Should be a standing order in triage to collect, but not order.
 
watermanMD said:
UA is part of too many nursing-driven protocols at my shop. Cough and fatigue? ****in’ urinalysis. Epigastric abdominal pain? ****in’ urinalysis. Even some UA’s on chest pain’ers.

Sometimes find myself unsure what to do with some of theses results—e.g. a positive nitrate or large leukocyte esterase + WBCs in patients with zero symptoms whatsoever. I know the sensitivity and specificity numbers (curious if those were derived from a symptomatic patient pop, or purely subsequent positive urine culture).

Just curious what you all are doing. I realize there’s, of course, nuance to this question but does anyone have a threshold for empirically treating – say a positive nitrate and any abdominal pain? How about an old patient with equivocal UA and vague, generalized malaise/ fatigue? What do you do with a disgusting looking urine in a patient without symptoms? I feel like most of my attendings in residency suggested I treat (cya mindset).

On a similar note, what are you giving for asymptomatic bactiuria in pregnancy?
Click to expand...

I'm relying less on urinalyses for many of those reasons. What is the chance that a healthy woman with epigastric pain has a *** UTI that is causing that pain. Just ridiculous.

I simply ask the patient: "Do you have problems peeing right now?" if the answer is No I don't give Abx.
 
brabbit2222 said:
Young and healthy but no dysuria - only if UA is a slam dunk UTI

For most patients when UA is vaguely positive I will go back and ask more in depth urine questions -- pain with urination, suprapubic discomfort, feeling like they aren't emptying fully, polyuria, foul urine smell -- those usually get antibiotics. Otherwise, I will wait for culture.
Click to expand...

I don't think in this population can have a UTI without symptoms. It's colonization or something else. It's like swabbing the throat, or skin, or gut flora. There is bacteria there but without symptoms it's not worth treating.
 
turkeyjerky said:
So, based on most of the above, I take it that I'm the only EM doc in the world who believes in asymptomatic bacteriuria? This would fit w/ my real life experience...

I love it when I see a + UA and document that clinically, it would represent asymptomatic bacteriuria and thus not merit treatment, but b/c there is an automatic reflex culture, invariably the patient gets called by f/u nurse and put on abx 2 days later.
Click to expand...

Agree.
 
Imagine swabbing every asymptomatic throat, skin, and aashole and send off the swab for culture, for someone to act on a few days later.

"Sir...I'm sorry to inform you that your rectum is infected. I know you came in for rib pain...but your butthole is infected. Here are some antibiotics."

Just ridiculous. We send 5x too many urines.
 
thegenius said:
Imagine swabbing every asymptomatic throat, skin, and aashole and send off the swab for culture, for someone to act on a few days later.

"Sir...I'm sorry to inform you that your rectum is infected. I know you came in for rib pain...but your butthole is infected. Here are some antibiotics."

Just ridiculous. We send 5x too many urines.
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Yep, I always makes sure to swab the perineum and send it off for culture. That way I know I can make a diagnosis of cellulitis to explain the vague weakness, dizziness, delirium, nausea, headache, abdominal pain, failure to thrive, whatever... Who cares about antibiotic resistance or adverse effects? Gives me and the patient an answer. I don't really care if it's the truth or not.

Crazy, you say? That's about what most urinalyses are worth. If you can't diagnose a UTI clinically, a UA or culture shouldn't be making the diagnosis for you.
 
coachB said:
Gives me and the patient an answer. I don't really care if it's the truth or not.
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This is the name of the game in urgent care. Everyone comes in for a goodie bag of sorts. Frequently it's abx. Dysuria when the patient turns out NOT to have a UTI was probably my least favorite complaint when I still worked in UC. It turns a 10 second dispo into at least 5 minutes explaining why they don't need antibiotics and how I don't know (or care) why it hurts when they pee. This then turns into a patient complaint when they don't get the aforementioned abx that they still feel they need because they are muggles who have no idea how medicine works.
 
Rekt said:
Probably the biggest crutch in EM. We joke about NPPs and the Zpak and steroid regimen, but I feel the same with a lot of EM docs and UAs. I almost never treat. Guess I shouldn't be surprised so many of you do on here. Unless it's pediatric, pregnant, or old (with very convincing UA) then they need real symptoms or no treatment. Most of the time these should not even been sent.

I try to cancel as many triage UAs as possible because it's pointless to even get the results on most patients. And "abdominal pain" is not a reason. There's likely a population variance. I would say 85% of the UAs at my ED are positive and looking at our patient population it's not surprising. Should be a standing order in triage to collect, but not order.
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I work with residents and PAs. I frequently am asking why a UA was even done in the first place. Often because they are saying something about the urine being "dirty" and then wanting to throw antibiotics at it. When they say "i don't know" or "just part of the belly pain work-up", I confirm whether symptoms present or not, and when the answer is no, I cancel antibiotics and gently remind them not to order tests without an indication.
 
BoardingDoc said:
This is the name of the game in urgent care. Everyone comes in for a goodie bag of sorts. Frequently it's abx. Dysuria when the patient turns out NOT to have a UTI was probably my least favorite complaint when I still worked in UC. It turns a 10 second dispo into at least 5 minutes explaining why they don't need antibiotics and how I don't know (or care) why it hurts when they pee. This then turns into a patient complaint when they don't get the aforementioned abx that they still feel they need because they are muggles who have no idea how medicine works.
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That's an easy one.

"Your urine shows no sign of infection, but being slightly dehydrated can cause similar symptoms. I want you to drink 3 liters of Gatorade over the next 24 hours. If that doesn't make you feel better, just let us know".
 
I routinely discontinue UAs ordered by nursing staff for most women and males unless they specifically came in for a GU complaint. I see some people treat UTIs with IV rocephin and then they get discharged with p.o. antibiotics. Like wft?

UA is different story in the elderly female population that comes in for "weakness" (UA is almost always positive). It gives me a diagnosis to get them discharged and family off my back after a negative workup.
 
I feel the not-a-UTI is such a source of headache and annoyances.

First you have the people who thinks everything is a UTI. "My urine smells" (yes, urine is a waste product) "my urine looks cloudy" "my urine looks dark" (Drink more). But then you have various "headache", "chills", "tired", "demented patient more demented today" because the last time they were the ED for that, their urine was tested and "positive", and continues to perpetuate the cycle.

Then you have the young interstitial cystitis patient who goes to the ED every month for a UTI for escalating amount of antibiotics but somehow their "UTI" never gets better, oh, and they never follow up with urology.

Then you have the patients sent by various doctors for IV antibiotics for ESBL organisms for a urine culture. Almost invariably none of them have any real UTI symptoms. Some of them have indwelling foleys in which a urine culture is sent off for no real reason. Some of the urologists put themselves on a list with the microbiology lab, so that when they order a urine culture, all bacteria that grows are fully speciated and sent for sensitivitity/specificity. So I get these patients sent in with 5 different urinary organisms that would require multiple IV antibiotics.

Also, recently, one of our local urgent cares are calling their patients back after the urine culture comes back to negative to tell them they don't have a UTI (which is fine), so they have to go to the Emergency Department because they don't have a UTI (WTF?)
 
turkeyjerky said:
Can we get this thread locked? Reading the last few posts is causing my HR and BP to skyrocket...way too much truth here...brb, gotta go punch a wall and run to blow off some steam
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Lol nope. I was my old hospital and nursing home’s antibiotic stewardship coordinator. I can’t lock it cuz I’m not an unbiased party on this topic. 😋
 
This entire thing is like the asymptomatic hypertension conversation.

Yes, you can spend half of your on-shift life explaining this to patients who come in at 2am because for some strange reason they decided to check their blood pressure as they were waiting for the microwave to heat up a midnight snack...

OR you can just order a BS CBC/CMP/trop/CXR/work-up, have them chill out in the WR, and magically dispo them 2 hours later (depending on if the chem panel machine is working or not) when surprise surprise, their repeat BP is now lower and "great news! your tests came back looking great!" Level 5 chart, happy patient/family, shows you "did something" and no real harm brought to the patient (I know some pedant is going to talk about the nebulous-on-an-individual-patient level iatrogenic harm this may cause, but in this medical climate it's just not a cultural priority).

The inertia behind the patient or patient's family anchoring on "last time it was a UTI!" is far too great. It's effectively in the public discourse now, and you're asking for a tough career trying to educate every single one of these patients/families. Don't get me wrong, there are a lot of them who will take your advice and knowledge with a giant heap of appreciation, but there are also a lot that simply DGAF about your expertise and just expect antibiotics/Rocephin/admission for "altered mental status" "dehydration" and "urinary tract infection."
 
PianoMedic said:
There was some recent study on macrobid causing some random issues with pregnancy, I think it was third trimester. As I’m too lazy to look it up, I tend to just avoid macrobid for the reasons tenk mentioned above. It also doesn’t penetrate the prostrate at all, just concentrates in the bladder. So it’s literally only good if they have a simple cystitis. If they have any other systemic symptoms, I would guess they could have some slight ureteral involvement and then macrobid is completely worthless as it won’t penetrate the tissue at all. I just use cephalexin or cefpodoxime or cefdinir. Bactrim for non elderly/non renal patients with anaphylactic pcn/cephalosporin allergies. Cipro or levaquin on occasion depending on prior cultures, or fosfomycin in certain circumstances, usually talking with pharmacy for that.
Click to expand...
hemolytic anemia in the newborn if at term (ok earlier in pregnancy)
 
pkwraith said:
Also, recently, one of our local urgent cares are calling their patients back after the urine culture comes back to negative to tell them they don't have a UTI (which is fine), so they have to go to the Emergency Department because they don't have a UTI (WTF?)
Click to expand...
This one is my favorite
 
HemorrhagicShock said:
This entire thing is like the asymptomatic hypertension conversation.

Yes, you can spend half of your on-shift life explaining this to patients who come in at 2am because for some strange reason they decided to check their blood pressure as they were waiting for the microwave to heat up a midnight snack...

OR you can just order a BS CBC/CMP/trop/CXR/work-up, have them chill out in the WR, and magically dispo them 2 hours later (depending on if the chem panel machine is working or not) when surprise surprise, their repeat BP is now lower and "great news! your tests came back looking great!" Level 5 chart, happy patient/family, shows you "did something" and no real harm brought to the patient (I know some pedant is going to talk about the nebulous-on-an-individual-patient level iatrogenic harm this may cause, but in this medical climate it's just not a cultural priority).

The inertia behind the patient or patient's family anchoring on "last time it was a UTI!" is far too great. It's effectively in the public discourse now, and you're asking for a tough career trying to educate every single one of these patients/families. Don't get me wrong, there are a lot of them who will take your advice and knowledge with a giant heap of appreciation, but there are also a lot that simply DGAF about your expertise and just expect antibiotics/Rocephin/admission for "altered mental status" "dehydration" and "urinary tract infection."
Click to expand...

Well....the whole reason why we have conversations about asymptomatic HTN and UAs is that people f'ing treat them. Don't treat it, and we will never talk about it!

BTW, the single biggest thing that any doctor does is educate their patient. What do you think pediatricians do all the time. I am aware that sometimes it's more pleasurable to stick your finger in your own eyeball, but most of the time you just say I'm not going to treat your asymptomatic HTN and UA and just move on. Rarely are you dragged in for a throwdown of epic proportions with a patient.
 
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