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by Tim Gieseke MD, CMD
I recently had an embarrassed nurse ask me whether he should call a patient’s physician to suggest a patient may not need an antibiotic for a + urine culture since the UA was clearly a contaminated collection and the patient was not having UTI symptoms. In this facility, the lab is immediately faxed to the attending physician’s office by our receptionist without review by the patient’s nurse. This improves the chances that the attending physician will see the report prior to leaving the office. In this situation, the physician received a + urine culture without the U/A accompanying it or any statement about the clinical reasons for the requested lab. In my experience, it’s common for attending physicians or the on-call physician to assume that the patient had a high clinical suspicion for a UTI, a consistent U/A, and therefore a need for an antibiotic.
In this case, I advised the nurse to call the attending physician, explain the situation and request he reconsider the necessity for this antibiotic. As stewards of infection prevention, we need to insure that antibiotics are only given to patients who need them. Our failure to do this subjects our patients to antibiotic side effects (common with most antibiotics), including the risk for C. difficile, and risk for ESBL and other multi-drug resistant organisms in our facilities. In addition 20-50% of older women are colonized and don’t need antibiotics for this asymptomatic bacteriuria. Urine collection is also difficult in our confused and frail patient population, with skin-contaminated urine specimens a common result.
In the acute hospital setting or office setting, physicians (and NPs or PAs) have the necessary information for UTI immediately available to them since they are usually the ones taking the history, documenting the concern, ordering the test, and receiving the results. In the SNF setting with attending providers off site, the management process may involve multiple clinicians, so we need to package the clinical information using a team approach.
I have worked with my facilities to develop this team approach. Please see our: Protocol for Management of Potential UTIs. You’re welcome to adapt it to your situation.
I look forward to your comments in future WAVE editions.
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Protocol for Improving the Management of Potential UTIs: Tim Gieseke MD, CMD 
Purpose: To insure that antibiotics are only given for a UTI after a patient is properly assessed and that information is effectively transmitted to the physician (NP/PA).
A possible UTI is suggested by:
1. Local bladder irritation symptoms:
a. Dysuria
b. Urgency
c. Suprapubic pressure
d. Frequency
e. New urinary incontinence.
2. Systemic symptoms including:
a. Warm, chills or rigors
b. Anorexia, nausea, vomiting
c. Weakness and reduced mobility with increased fall risk
d. CNS dysfunction (confusion, sleepiness, short attention span).
3. Systemic signs:
a. Fever – temp 2 degrees > baseline temp
b. Tachycardia – rate increase > 25 from baseline
c. Pallor & diaphoresis
d. Flushing
e. Hypotension – SBP < 25 mm below baseline
A request for a Urinalysis is appropriate if above evidence for a UTI is present, but is not warranted if the only concern is a bad behavior.
Notify the physician (NP/PA) by:
1. Fax, if the symptoms are only local and the patient is not having symptoms or signs of systemic illness.
2. Call, if systemic symptoms and or signs are present.
If a UA is requested and ordered, a clean urine specimen must be collected.
1. Obtain a mid-stream clean catch urine specimen if this is possible. If it’s not clean, that UA should be thrown away.
2. If #1 is not possible, a UA should be collected by Fem-catheter or an In & Out catheter using sterile technique.
This urine specimen should be sent to the lab with a request for microscopic examination of the specimen and a request for a reflex culture and sensitivity if there are more than 10 WBC/hpf in the microscopic examination.
Ideally, antibiotics should not be started until after this urine specimen is collected.
When the UA results return, the facility will have the attending nurse review the UA report for:
1. Excessive epithelial cells that may suggest the specimen is a contaminated collection that won’t produce a reliable culture (Skin contamination present)
2. Excessive RBC’s which may reflect traumatic catheter collection, a migrating kidney stone, or a GU tumor.
The nurse will then write a brief summary on the UA report of the clinical reasons the UA was sent and whether the specimen was a clean catch or catheterized specimen.
1. The UA will then be faxed to the attending physician (NP/PA) if the patient is medically stable
2. If the patient is sick with a possible UTI and not yet on antibiotics, the physician (NP/PA) will be called.
When the urine culture returns, the facility will have the attending nurse review the UA report with clinical data noted above. She will then:
1. Consider whether the patient likely has a UTI or is only colonized, or whether the urine specimen was likely contaminated.
2. The nurse should fax this UA with clinical information and the culture report to the physician (NP/PA) if the patient is:
a. Colonized or specimen is likely contaminated
b. Not sick and not on antibiotic
c. Not sick and on wrong antibiotic
d. Sick, but on an antibiotic for which the organism is sensitive and the patient is clinically doing better.
3. The nurse should call the physician (NP/PA) if the patient:
a. Is sick and not yet on an antibiotic
b. Is sick and the bacteria is resistant to the chosen antibiotic
c. Is sick, on a sensitive antibiotic, but not clinically improving
Protocol Adopted:
Protocol Reviewed:
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