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.