Deep Dive #6: Bacteriuria and the Elderly

Author: Heidi Wald, MD, MSPH 

Associate Professor of Medicine – University of Colorado School of Medicine, Physician Advisor – Colorado Hospital Association

Dr. Heidi Wald explains common misconceptions of UTI’s in elderly patients and provides tips on how to properly identify them.

References:

Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici  Antibiotics for asymptomatic bacteriuria  Cochrane Collaborative Online Publication Date: April 2015.

Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.

Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015.

D’Agata ELoeb MB, and Mitchell.  Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070.

Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

Podcast #216: Roller Coasters and Kidney Stones

Author: Aaron Lessen, M.D.

Educational Pearls:

  • Anecdotal evidence suggests that roller coasters may help with kidney stones.
  • A recent study used a model of a kidney and ureter with different sized stones and put it on Thunder Mountain roller coaster in Disney World.
  • There was “dramatic passage” of the kidney stones at the rear of the roller coaster.

References: Marc A. Mitchell, DO; David D. Wartinger, DO, JD. Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association, October 2016, Vol. 116, 647-652. doi:10.7556/jaoa.2016.128. http://jaoa.org/article.aspx?articleid=2557373

 

Podcast #131: Antibiotics for a UTI

0242783e-863a-451d-a9e4-4455434c30daRun Time: 4 minutes

Author: Holly Anderson, PharmD PGY-1 Resident

Educational Pearls:

  • Patients with pyelonephritis typically show a leukocytosis, fever, nausea, HA, CVA tenderness. Patients with a lower tract UTI will have absence of systemic symptoms with predominantly voiding symptoms of frequency, urgency, dysuria, and hematuria. These 2 types of UTI require different antibiotics and treatment.
  • Based on IDSA guidelines, only patients with uncomplicated lower UTI should be receiving Macrobid.
  • For patients with uncomplicated pyelonephritis, fluoroquinolones and Bactrim are preferred.
  • Macrobid has good sensitivity for the classic bugs that cause UTI, while fluoroquinolones show increasing E. coli resistance and are not recommended for uncomplicated lower tract UTIs.
  • Macrobid should not be used for pyelonephritis because the medication penetrates to the bladder just fine, but not well enough to the kidneys.

Link to Podcast: http://medicalminute.madewithopinion.com/antibiotics-for-a-uti/ 

References: http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_by_Organ_System/Genitourinary/Uncomplicated_Cystitis_and_Pyelonephritis_(UTI)/

Podcast #116: Catch a UA in Infants

733e8ff1-5e09-4aff-ba9b-42d299223775Run Time: 2 minutes

Author: Dylan Luyten M.D.

Educational Pearls:

  • An upcoming study in the Journal of Pediatrics, to be published in July, looked at reducing unnecessary urinary catheterization rates in infants.
  • In the study they investigated bagged urines on infants and every infant got a catheter.
  • It was found that if you restricted true positive UA on the bagged kids to those with positive nitrites, and moderate to large leuk esterase; there were no missed UTIs if you only catheterized these kids.
  • This could potentially reduce the number of catheterizations necessary for infants coming to the Emergency Room.

Link to Podcast: http://medicalminute.madewithopinion.com/catch-a-ua-in-infants/

References: http://www.jpeds.com/article/S0022-3476(09)00010-9/fulltext

Podcast #113: ASB vs. UTI

4d6bc5b7-0b1d-4d12-abe4-c0bbc2e4bed5Run Time: 4 minutes

Author: Holly Anderson, PharmD PGY-1 Resident

Educational Pearls:

  • ASB is defined as an individual with a bacteria count >100,00 or pyuria present on UA.
  • Patients will likely present with another chief complaint and will have no localizing urinary symptoms.
  • ASB is common in elderly patient with an indwelling catheter which frequently will be colonized with bacteria, up to 100% positive presence of ASB in patients with a long-term indwelling catheter. However, this does not mean the patient has a true UTI.
  • For patients with a suspected UTI think of the following algorithm to determine if the patient is truly in need of antibiotics: Are there localizing UTI symptoms? No, then there is no need for UA/culture. Yes, then is there an alternative cause or diagnosis? Yes, evaluate the other suspected cause. No, send UA & urine culture, start the patient on empiric antibiotics, and follow up in 48 hours to determine if the patient truly needs the antibiotics.

 

Link to Podcast: http://medicalminute.madewithopinion.com/asb-vs-uti/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534219/

Podcast #73: Imaging for Kidney Stones

Run Time: 3 minutesscreen-shot-2013-04-17-at-12-45-57-pm

Author: Dr. Jared Scott

Educational Pearls:

  • From 1992 to 2009, the number of CTs used to diagnose kidney stones has tripled. The radiation given by a CT of the abdomen and pelvis is roughly equivalent to the radiation given by 100 chest Xrays.
  • American College of Radiologygg reports even one CT scan increases your lifetime risk of getting cancer.
  • An ultrasound can visualize hydronephrosis, which indicates a large kidney stone is present.

Link to Podcast:  http://medicalminute.madewithopinion.com/imaging-for-kidney-stones/

References:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3587076/

https://www.auanet.org/education/kidney-stones.cfm

Podcast #66: Medications for Kidney Stones

Run Time: 4 minutesblausen_0595_kidneystones

Author: Dr. Jared Scott

Educational Pearls:

  • NSAIDS should be prescribed for all patients with kidney stones. This helps to reduce the hyperactivity of your ureter.
  • Narcotics work well for treating kidney stone pain. This should be accompanied by NSAIDS for best results.
  • Using diuretics or fluid therapy do not significantly treat kidney stones.
  • Alpha-blockers, despite currently being used to treat kidney stones, have been shown to have no efficacy or limited efficacy for stones greater than 5 mm.

Link to Podcast:  http://medicalminute.madewithopinion.com/meds-for-kidney-stones/

References:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313741/

http://www.cochrane.org/CD006027/RENAL_nonsteroidal-anti-inflammatory-drugs-are-effective-treatment-for-acute-renal-colic

http://www.cochrane.org/CD004292/RENAL_increased-water-intake-may-help-reduce-the-risk-of-recurrence-of-kidney-stones-but-more-studies-are-needed

http://www.cochrane.org/CD008509/RENAL_alpha-blockers-as-medical-expulsive-therapy-for-ureteral-stones

Podcast #47: Broken Penis

Run Time: 2 minutesbroken-penis

Author: Dr. Erik Verzemnieks

Educational Pearls:

  • During an erection the corpus cavanosum fills with blood, when enough stress is placed on the penis during an erection the surrounding tissue can rupture.
  • A broken penis most often occurs during intercourse in the “reverse cowgirl” position.
  • This condition requires surgical repair of the penis to prevent tearing of the penile veins or the urethra.

Link to Podcast: http://medicalminute.madewithopinion.com/broken-penis-1/


References: 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472832/

Podcast #28: Flomax and Kidney Stones

b8015bae-2f8a-4977-837e-2e4ab1a17011Run Time: 4 minutes

Author: Dr. Samuel Killian

Educational Pearls:

  • Greater than 1 million visits per year in American for kidney stones.
  • 12% men and 6% women will have kidney stone at some point during their lifetime.
  • Most studies that discredited Flomax were not properly organized – there was no placebo, the study was not blind, etc.
  • New study from the Annals of Emergency Medicine showed that 87% of patients who received Flomax passed there stone at 28 days and 82% who received the placebo also passed their stone at 28 days, regardless of stone size.
  • The difference was at 5-10mm stones. 82% w/ Flomax passed their stone at 28 days and only 60% who received the placebo passed their stone at 28 days.

Link to Podcast:  http://medicalminute.madewithopinion.com/flomax-and-kidney-stones/

References:  http://www.annemergmed.com/article/S0196-0644(08)02183-5/fulltext