Comment

Dipstick urine test advice misses the point

Advice against using dipsticks to identify urinary tract infections in people over 65 appears flawed

Advice against using dipsticks to identify urinary tract infections in people over 65 appears flawed, says Bethann Siviter


GP comparing a patient’s urine test strip against a reference chart. Urine analysis is
used to test for diabetes, kidney problems and urinary tract infections. Picture: SPL

Guidance advising against using dipsticks to identify urinary tract infections (UTI) in people over 65 has been published by Public Health England and the National Institute for Health and Care Excellence (NICE).

Although urine dipsticks have a role in diagnostics, many people in that age group have asymptomatic bacteriuria, so the dipsticks results are unreliable, the guidance says.

The British Medical Association’s GP Committee clinical and prescribing policy lead Andrew Green is quoted as telling Pulse magazine: ‘We would fully support this. GPs are often inundated with urine specimens from care and nursing homes taken without good reason.’

Why send them to a GP?

The dipping of a urine specimen had potential harms and should only be performed in specific circumstances, Dr Green is quoted as saying.

This made me wonder why care homes were sending urine samples for a GP to dip instead of doing it themselves, or calling district nurses, and it conjured up an image of a GP sitting in an office stacked with urine samples. Maybe I just get distracted easily.

The potential harms of urine dipsticking are highlighted. This worries me, as it is well known that the ‘dipstick relay’ is one of the most popular events in the nursing pentathlon, being nearly equal to the ‘compression bandaging marathon’ and the ‘blood pressure clinic dash’.

Complex fluid balance

Guidance says dipsticks are only contraindicated when the person is asymptomatic. When there are symptoms of a UTI it is still appropriate. But odour, cloudy urine and confusion are not symptoms anymore – the guidance says these can also be present in asymptomatic UTI.

Yet when dealing with an aged population with reduced cognition, incontinence with frequency and urgency, and an inability to report things such as pain, how would we even know when a UTI was present?

The harm from dipsticking comes from overuse of antibiotics, leading to increased resistance. As we know, dehydration and untreated UTI can lead to acute kidney injury, and UTI can lead to sepsis. It’s a complex fluid balance.

Hydration in the community

To help reduce the risk of UTI, guidance from NICE calls for improved hydration in care homes. That’s great, but community nurses know well that people living at home are at serious risk of dehydration.

Where is the monitoring and care to ensure hydration for people in the community?

Another community problem is that people are reluctant to drink because they will then pass urine, which means getting up to go to the loo or having to change a pad, but needing to wait several hours for help.

Indicator of efficacy?

Continence services supply one pad for every eight hours. Is that enough to balance the result of good hydration?

The NICE guidance looks at one indicator of efficacy as a reduction in the provision of the antibiotic Trimethoprim. Clearly, if we are giving out fewer antibiotics we are treating people appropriately, right?

Guidance has been released on identifying acute kidney injury and good microbial stewardship, but the key message people are latching onto seems to be ‘don’t dipstick urine anymore’. Isn’t that missing the point?

What the message should be

The message should be this: ‘Put all necessary steps in place to ensure not only that people are hydrated, but also that symptoms of a UTI are recognised and appropriately treated even when people are older and have cognitive impairment or urinary issues.’

There is also a need for nurses, nurse associates and care workers to have formal training in ensuring hydration, as well as on how to recognise and assess UTI and sepsis.

Recognising sepsis will be especially important if we are not treating UTIs anymore. At least then they will know it’s a real infection, without cluttering up a GP’s desk with urine pots.


Bethann Siviter is an independent nursing consultant

 

 

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