A Guide to: Urinalysis in the Older Adult / Care Home Environment

Urinalysis Guidelines April 2018 Approval: March18 Review: March21

On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG A Guide to: Urinalysis in the Older Adult / Care Home Environment

The following guidance has been developed to support the improved quality of care for older people living in care homes with a suspected Urinary Tract Infection (UTI) and focuses on prevention, improving diagnosis and management.

The guide should be used in conjunction with the ‘Care Home Flow Chart’ available at: www.worcestershirehealth.nhs.uk/infection-control-service/nursing-care-homes/urinary-tract-infection/

Urinalysis is a simple and cheap method of monitoring a person’s health status. The make-up of the urine can change quite dramatically in response to illness. Inappropriate use of dip-stick testing of urine can lead to over-diagnosis of UTIs, unnecessary prescribing of antibiotics with no positive benefit which can result in medication-related complications such as antimicrobial resistance and Clostridium difficile.

UTI is the second most common reason for using antibiotics in primary care, particularly in older people who are resident in nursing homes and diagnosis can be difficult. Urine samples form the largest single group of specimens examined in most laboratories. Studies have shown that 40% men, 50% women and 100% of people with urinary catheters will have bacteria in their urine without infection being present.

Urinary Tract Infection Testing Algorithm (Adults)

Suspected UTI: The most significant markers of a UTI are leukocyte esterase (LE) and nitrites

• Pain on urination / dysuria • New or worsening urinary incontinence • Urgency • Side of body (flank) or suprapubic pain • Frequency • Visible blood in urine / haematuria • Shaking chills (rigors) • New onset or worsening of pre-existing confusion or / agitation

Dipstick test using unborated urine (no boric acid) for leukocyte esterase and nitrites

Dipstick displays any amount of leukocyte esterase Both leukocyte esterase and nitrites are negative AND / OR nitrites

No evidence of UTI Continue to monitor Send a MSU in boric acid for culture Do not send MSU

Mildly Unwell May be appropriate to withhold Consider treatment if clinical symptoms strongly treatment pending lab results suggest urinary infection

Consider pain relief, fluid input / hydration

2 Urinalysis Guidelines April 2018 Review: March21 It is important to remember that:

• Odour or cloudiness alone is not indicative of UTI and no reason to test urine • Smelly or dark urine alone are not signs of a UTI but may indicate dehydration • Cloudy urine and bacteriuria are expected in all patients with a urinary catheter • Bacteria in the urine does not always mean infection is present • Do not do a dipstick if the resident is not unwell • Do not send urine for culture for residents with positive dipsticks but no other symptoms.

Suspect a UTI when one or more of the following are present:

• Pain on urination/dysuria (symptom of pain, discomfort or burning when urinating) • Frequent passing of urine or urge to pass urine • Bladder or renal pain (lower abdomen or flanks) • Recent onset or worsening incontinence.

Also consider UTI if unexplained:

• Fever > 38˚C; or < 36˚C • Malaise; or • Nausea and/or vomiting; or • New onset or worsening of confusion / agitation

But more likely to be UTI if:

• Specific UTI symptoms are present • If history of previous illness with UTI

Fluid intake should be maintained and hydration promoted particularly if a UTI is suspected or confirmed and a GP should be consulted urgently if the resident is significantly unwell.

Diagnosis

Accurate diagnosis of UTI’s in care home residents requires judgement of a combination of clinical signs and Diagnosis of a UTI in symptoms and a positive urine culture. Urine culture is the most useful test the elderly requires a when a UTI is clinically suspected, combination of reliable both to support the diagnosis and provide antibiotic sensitivities. clinical signs and symptoms

Susceptibility results are essential to and a positive MSU result. guide treatment. Urine culture results should be used to de-escalate or change therapy, if needed, and the A dipstick urinalysis recommended duration of therapy alone is NOT reliable. should be followed to prevent excessive antimicrobial exposure.

Urinalysis Guidelines April 2018 Review: March21 3 Obtaining a Urine Sample:

Send urine for culture if two or more signs of infection, especially dysuria, fever > 38° C or new incontinence are present. If an MSU is not possible a ‘clean catch’ can be collected although results may not be as reliable. Before obtaining a specimen of urine ensure that the resident’s GP or the nurse in charge is aware of the presenting symptoms and is aware of and has consented to a specimen being obtained.

• A positive MSU with no symptoms indicates bacteriuria (not an infection). Continue to monitor and observe • A positive MSU with symptoms supports the diagnosis of UTI • Do not send urine for culture in asymptomatic elderly with positive dipsticks.

The specimen should be sent in the appropriate container with boric acid. Boric acid is a preservative allowing for storage and transportation in the community setting. Please refer to Appendix 1 for obtaining a MSU using the Urine Monovette with Boric Acid and Appendix 2 for obtaining a CSU using the Urine Monovette. Appendix 4 details the use of the Uricol Urine Collecting System.

Dipstick Urinalysis (Appendix 3):

A urine test strip or dipstick test is a basic diagnostic tool used to determine pathological changes in a patient’s urine in standard urinalysis. A standard urine test strip may comprise up to 10 different chemical pads or reagents which react (change colour) when immersed in, and then removed from, a urine sample. The most significant markers of a UTI are leukocyte esterase and nitrite. There may also be other markers such as protein and glucose. These are unrelated to infection but are often present in the urine of older people.

What does a Positive Dipstick mean?

Positive for Leucocytes (pyuria/pus, white blood cells):

1. This relies on the reaction of leukocyte esterase produced by neutrophils and a positive result suggests pyuria associated with a UTI 2. Shows the presence of white blood cells 3. Can be produced by the presence of bacteria, but may be contamination 4. Is not always present when infection is present 5. False positive results are common.

Positive for Nitrites:

1. This relies on the breakdown of urinary nitrates to nitrites, which are not found in normal urine 2. Some bacteria can produce this reaction and a positive result suggests their presence.

Bacteria maybe the cause of nitrites and leucocytes being present however these alone do not mean there is an infection present. Indirect indicators of the presence of bacteria (for example, urinary nitrites) are likely to be much less valuable than urine culture. Accurate diagnosis therefore requires the judgement of a combination of clinical signs and symptoms and a positive urine culture (MSU/CSU).

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 are present.

4 Urinalysis Guidelines April 2018 Review: March21 What’s the harm in doing a dipstick test?

It is difficult to ignore a positive result even if it doesn’t mean very much at all.

It can be difficult to assess an older person and therefore relying on the urine dipstick result may result in another diagnosis being missed altogether.

It can also trigger antibiotics being prescribed.

Treatment of a UTI/CAUTI:

Treatment depends on the clinical condition - if the resident is mildly unwell then it may be appropriate to wait for the culture result rather than initiate treatment while it is still unclear whether a UTI is present or not. The GP will decide.

Residents may be treated with antibiotics to help clear the infection, it is important that they finish the course of antibiotics even after symptoms have resolved. Fluid intake should be maintained and hydration promoted.

Useful Links:

Primary Care Prescribing Guidance: www.southworcsccg.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=95546

‘To dip or not to dip’ training animation: youtu.be/rZ5T1Cz7DHQ

Further information on UTI’s can be found at: www.worcestershirehealth.nhs.uk/infection-control-service/nursing-care-homes/

Appendix 1: Obtaining a Midstream Specimen of Urine (MSU)

This involves taking a ‘middle’ sample while the resident is urinating, avoiding the initial and end stages of the urination. This method reduces the risk of sample contamination from bacteria colonised around the urethra as these bacteria are washed away with the initial urine flow. The most appropriate time to collect a sample is when the bladder is full as a strong flow of urine is more effective in clearing bacteria from the urethral meatus.

To collect an MSU you will require:

• Clean disposable cup, Urine Monovette ( Worcestershire/Herefordshire lab ) or sterile specimen pot ( boric acid) and an appropriate lab request form. • Personal Protective Equipment PPE (apron and gloves and eye protection if needed). • Consent.

Urinalysis Guidelines April 2018 Review: March21 5 Procedure

1. Cleanse hands thoroughly. 2. Put on PPE - Apron and gloves, wear face protection if a risk of splash or spray of urine. 3. Pre-cleaning for women, the labia should be separated with cotton wool or a clean sponge moistened with water, and the vulva should be wiped from the front to the back although disinfectant must never be used. Men should clean the glans penis with soap and water. Ask the patient to retract the foreskin and clean the skin surrounding the urethral meatus with soap and water, 0.9% sodium chloride or a disinfectant-free solution. 4. Ask the resident to start voiding / going to the toilet. 5. During the middle of the void (as indicated by the person) or after a few seconds place the clean plastic cup/sterile specimen pot into the urine stream, without interrupting flow and collect the urine sample. 6. Remove cup/pot and allow the person to finish voiding. 7. Following the Monovette guidelines (attached below), fill the Monovette up to the bottom of the label or secure the lid of the specimen pot. Complete the process. 8. Remove gloves, apron and eye protection and cleanse your hands, also remember to offer the resident the opportunity to wash their hands. 9. Complete the documentation, label Monovette/specimen pot, accompanying form and nursing notes. 10. Dispatch sample to laboratory immediately (within 4 hours) or refrigerate (4°C). If using the ‘Urine-Monovette’ this is stable at room temperature for 48 hrs between sampling and analysis.

Monovette Guidance with Boric Acid User Guide: Urine Monovette® with Boric Acid - User Guide

1 2 3 4 5

®

®

® Waste Technical modifications reserved Technical

Remove stopper and Insert the plastic straw into To empty the plastic straw, Remove the plastic straw, break Mix well after sample collection keep for later use! the container and fill the hold the Urine Monovette® in off plunger and throw away. (tilt approx. 5 times). ® position and pull the Attach plastic straw. Urine Monovette up to an upright Replace the stopper. PI 263-0109 the bottom of the label. plunger backwards to the bottom of the tube.

SARSTEDT Ltd. 68 Boston Rd, Leicester LE4 1AW Tel.: 0116 235 9023 Fax: 0116 236 6099 [email protected] 6www.sarstedt.com Urinalysis Guidelines April 2018 Review: March21 Appendix 2: Taking a Catheter Specimen of Urine (CSU)

Procedure

1. Discuss the procedure with the resident/patient 2. Prepare equipment - apron, gloves and wipe ( 70% isopropyl alcohol or 2% chlorhexidine in 70% isopropyl - for medical devices), ’Urine Monovette’ with boric acid. 3. If no urine visible in catheter tubing: wash/decontaminate physically clean hands with alcohol rub, don apron and apply non-sterile gloves prior to manipulating the catheter tubing. 4. Apply non-traumatic clamp a few centimetres below the sampling port. Use the drainage bag tubing for this purpose, never the catheter. 5. Wash hands, or decontaminate physically clean hands with hand sanitizer and put on gloves. 6. Wipe sampling port with 70% isopropyl or 2% chlorhexidine in 70% isopropyl alcohol wipe and allow the area to dry for 30 seconds. 7. Needle free procedure - insert Urine-Monovette /syringe firmly into centre sampling port (according to manufacturer’s guidelines), aspirate the required amount of urine and remove Urine-Monovette/ syringe. 8. Wipe the sampling port with an alcohol wipe and allow to dry. 9. Unclamp tubing. 10. Dispose of waste, remove gloves and apron and cleanse hands thoroughly. 11. Label sample and complete microbiological request form including relevant clinical information, such as signs and symptoms of infection and antibiotic therapy. 12. Dispatch sample to laboratory immediately (within 4 hours) or refrigerate at 4°C. If using the ‘Urine-Monovette’ this is stable at room temperature for 48 hrs between sampling and analysis. 13. Document the procedure in the patient’s records.

Urinalysis Guidelines April 2018 Review: March21 7 Urine-Monovette Procedure for Obtaining a CSU:

1) If necessary, clamp the tubing a few centimetres distal to the sampling site. The sampling segment must be filled with urine.

2) Disinfect the sampling site on the catheter according to institutional guidelines. 3a 3b 5230 4

¨ 3a) Remove the stopper of the Urine-Monovette® and keep

Z for later use. Z 5230 3b) Pierce the centre of the membrane at the sampling site with the Luer tip of the sterile Urine-Monovette®.

5 6 4) Fill the Urine-Monovette® with urine by completely withdrawing the plunger.

waste ¨

¨

Z 5) Break off the plunger and

throw away.5230 Replace the stopper.

6) If using the Urine-Monovette ® with boric acid, mix well5230 after sample collection (tilt approximately 5 times).

8 Urinalysis Guidelines April 2018 Review: March21 Appendix 3: Urinalysis Procedure (Urine Dipstick Test)

Procedure

1. Assemble the required equipment:

- Test strips (stored in line with manufacturer’s guidance) - Urine sample - Apron/gloves - Clean wipeable surface to undertake the procedure - Tissue/absorbent paper towel - Wipes to clean surface before and afterwards - Watch/clock.

2. Check the test strips are inside the stated expiry date. Check the urine sample is fresh (< 2 hrs. since voiding) – observe the colour and odour. Cloudy urine may indicate the sample is contaminated or infection is present. A strong fishy smell may indicate infection and a sweet odour like pear drop sweets may indicate ketones are present. Check the sample is from the correct person and note any medications they are taking (as some medications may affect the result). 3. Wearing apron and gloves remove a test strip from the pot and replace the lid. 4. Immerse the full length of the test strip in the urine for no longer than 1 second 5. Run edge of strip along the container to remove excess urine. 6. Place the test strip on the tissue/absorbent paper to prevent the colours on the pads contaminating each other. Start the timer/note the time. Replace the lid on the urine specimen. 7. When the appropriate amount of time has passed (usually 60 seconds), align the test pads with the corresponding result gauge on the test strip bottle. Hold the dipstick horizontally before reading. Be sure to line the pads up with the corresponding test on the container. This is where most errors with urine testing are made! Do not let the urine test strip touch the container as this is a contamination hazard. 8. If the urine is not being send for culture then dispose of it down a toilet/ sluice. Place all used equipment in the appropriate waste bag. 9. Wipe down surface. 10. Remove gloves and apron and cleanse hands. 11. Document urinalysis readings and report any abnormal result as appropriate. 12. To avoid accidental contamination of the environment a urine dip stick is best preformed in a designated area / sluice or by placing equipment on a dedicated plastic tray with raised sides.

Urinalysis Container:

Urinalysis Guidelines April 2018 Review: March21 9 Appendix 4: Uricol – the Newcastle Urine Collector

A product used to collect a urine sample from an incontinent adult or baby, when a standard sample is unobtainable. The urine sample is collected on the pads, which are laid in the incontinence pad or nappy. The urine is then extracted from the pad using the syringe and then transferred into the specimen bottle or Urine Monovette.

Included in each kit:

• Two sample pads • Syringe • Specimen bottle.

Procedure

1. Ensure the persons genital area and bottom is washed using soap and water, drying from front to back. Do not apply any creams or talcum powder. 2. Ensure the Uricol pad is positioned over the area where the person passes urine (excepted void area). 3. Check at 10 minute intervals to see if the pad is wet. If after 30 minutes the pad is not wet then a new pad must be put in place and the process started again. 4. As soon as the pad is wet, remove it. This should be completed wearing an apron and gloves. If the pad is soiled the process will need to be repeated. 5. Lay the pad on a clean, flat, intact surface, wet side up. Ensure contamination risk of surface is considered and ensure surface is cleaned thoroughly following sampling. 6. Take the syringe, place the tip on the pad at an angle of 45 degrees and pull up the plunger to extract the urine from the pad. This can also be done using the Urine Monovette system if the sample is solely for laboratory testing. 7. If using a syringe, hold the tip of the syringe over the sterile sample pot or clean cup. Press the plunger down to express the urine. This process may need to be completed several times to ensure sufficient urine is available. The urine sample can then be dip stick tested or sent for testing. 8. Dispose of equipment and clean surface in line with local guidelines. 9. Remove gloves and apron and cleanse hands.

10 Urinalysis Guidelines April 2018 Review: March21 References:

RCN. Urine Testing. rcnhca.org.uk/clinical-skills/observation/urine-testing

Health Improvement Scotland. Management of suspected bacterial UTI in adults. www.sign.ac.uk/sign-88-management-of-suspected-bacterial-urinary-tract-infection-in-adults.html

PHE. Managing common infections: guidance for primary care. www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care

Nursing Times (2008) Specimen Collection 1. Obtaining a Midstream Specimen of Urine. www.nursingtimes.net/clinical-archive/infection-control/specimen-collection-1-obtaining-a-midstream- specimen-of-urine/1295662.article

Sarstedt. Monovette Guidance www.mtw.nhs.uk/wp-content/uploads/2015/08/Monovette-user-guide.pdf

Patient Information (12/03/2014). Urine Dipstick Analysis. patient.info/doctor/urine-dipstick-analysis

Royal Marsden Manual of Clinical Nursing procedures. Ninth Edition. www.rmmonline.co.uk

To Dip or Not to Dip (24/4/2017). Training Animation. youtu.be/rZ5T1Cz7DHQ

Urinalysis Guidelines April 2018 Review: March21 11