Who’s taking the urine?

Or who is responsible for sending urine samples to the laboratory and why?

I’ve used a variation of that title as part of the title for a number of presentations I’ve been giving across our local health board area, in an attempt to grab my audience attention.

What’s the issue?

Innapropriate use of antibiotics, particularly in our older population, to treat alledged urinary tract infection.  Indeed, this article is prompted by a conversation this morning with one of my biomedical scientists in the lab.  We were discussing the whole issue of interpretation of microbiology results and management of infection.  She told me that her mother has made regular trips to the surgery to see the practice nurse, taking a urine sample because she has “recurrent urinary tract infection.”  The nurse sticks a dip-stick in the urine, gets some positive results and says she has a UTI and offers her a 3 day course of antibiotics.  When I asked about urinary symptoms, I’m told she has none of the symptoms or signs that are required to make a diagnosis of UTI.

Potentially, this older lady is now riding a slippery slope, swallowing antibioitcs that will be having a detrimental effect of her normal bowel flora and selecting for resistant bacteria.  Now if she were to get a true UTI, with all the attendent effects of frequent urination, pain on passing urine and possible fever, the choice of antibiotics to treat this true infection may be limited.

The diagnosis of UTI cannot be made by dipstick or indeed by the laboratory.  The diagnosis is made clinically on the basis of signs and symptoms.  For general practice, there is a flow chart, published by Public Health England that guides the clinician through the steps.  This flow chart explains the place of the dipstick, which is used to help in determining if the symptoms and signs the patient has represent UTI or some other diagnosis.  There is no place for screening urines by dipstick.

Don’t “dip” urines innapropriately

This is not the first of these anecdotes I have heard.  We hear of similar bad practices becoming normalised in many wards and departments in our hospitals, usually from the best of intentions where staff are trying their best to get one jump ahead of what is happening in their patients.  If a patient is in a collapsed state, with signs of infection, staff will do everything they can to get to the bottom of the issue quickly so as to institute a rapid management plan, which may be life saving.  This may include dipping urine in an effort to help the diagnostic conundrum and basing a treatment decision on that acute result is perfectly reasonable.  However, when we then get management drift and I see a request card coming into tha lab that says, “Routine daily check,” alarm bells go off.

Why does this matter?

Across Hywel Dda we are seeing an increasing number of serious infections presenting in our hospitals.  Most of these are in our older population.  As my paper in 2014 to the health board highlighted, the largest increase we are seeing is in serious infection with E. coli as meassured by blood stream infection.  Given that E. coli is the commonest laboratory demonstrated cause of UTI, I worry there is a link between inappropriate sampling of urine, missdiagnosis of UTI and innappropriate antibioitc prescribing.  By highlighting this issue wherever I get the opportunity I can perhaps influence the population as a whole a well as health professionals.