9HOW ACCURATE IS OUR DIAGNOSIS OF A URINARY TRACT INFECTION?

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Abstract

Background: Frail elderly patients often present with non-specific symptoms and a common diagnosis made is urinary tract infection (UTI) based on a positive urine dipstick. The Royal College of Physicians acute care toolkit 3 recommended against performing a routine dipstick of urine in these patients unless they had clinical signs of sepsis or had urinary symptoms.

Method: Patients over the age of 75 who were admitted via the acute unselected take to Southport and Ormskirk NHS Trust were assessed at random. The presenting complaint and the diagnosis from the consultant post take ward round were included in our analysis with the biochemical and microbiology results.

Results: 47 patients were reviewed. Presenting complaints included fever (14.9%), delirium (34%), collapse / falls (23.4%), urinary symptoms (6.4%), non-specific symptoms (21.3%).

Dipstick urine was positive for nitrates and/or leucocytes in 70.2% of patients. 46/47 (97.8%) were treated with antibiotics for a presumed UTI. Trimethoprim was used in 47.9%, Cefuroxime in 39.1% and in 8.7% of patients, a variety of other antibiotics were used.

A midstream urine sample (MSSU) was sent in 39/46 (84.7%) of the patients who were given a diagnosis of a UTI. Of those, 14/39 (35.9%) were positive with a microorganism. However, only 7 of these patients had symptoms or signs of sepsis consistent with a clinically significant urinary tract infection (ie 15% of those treated).

Conclusion: Dipstick urine should not be used to diagnose UTIs as it leads to over-diagnosis and the over-use of antibiotics with the concomitant risk of multi-resistant organisms and clostridium difficile infection. Positive urine culture is obtained in only a small proportion of those with positive dipstick tests. It is very important to differentiate between a clinically significant UTI or asymptomatic bacteruria as other causes of sepsis or clinical deterioration could be missed.

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