From the July 2014 issue of Emergency Medicine Practice, “Diagnosis and Management of Urinary Tract Infections in the Emergency Department.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to ebmedicine.net/emra, call 1-800-249-5770, or send e-mail to ebm@ebmedicine.net.
- “Fever and tachycardia are routine with pyelonephritis, and I only need to screen for sepsis if the patient looks septic.”
The definition of sepsis has recently been defined much more broadly by the Surviving Sepsis Campaign guidelines. A patient needs only to have a source of infection and 2 of 24 criteria positive to meet the current definition for the diagnosis of sepsis. Fever and tachycardia, which are frequently present in pyelonephritis, qualify the patient as having sepsis by the Surviving Sepsis Campaign guidelines. Nonetheless, in our view, the criteria for sepsis cannot be interpreted to mean that every patient who presents febrile and tachycardic must be admitted. Rather, the presence of fever and tachycardia should serve as a trigger to treat the fever and tachycardia and to consider further workup for the presence of sepsis as a definite process. IV fluids are indicated as well as treatment of the fever. Further laboratory tests (such as a complete blood count, a basic metabolic profile, and a lactate level) can be considered to see if more criteria for sepsis are present. Select patients can be safely sent home on a case-by-case basis; the first dose of parenteral antibiotics prior to discharge and mandatory follow-up in 24 hours is warranted. - “I don't think about also prescribing pain and nausea medications for home.”
Patients return to the ED for preventable and unpreventable reasons. Unpreventable reasons include new resistance patterns and poor response to appropriate therapy. Preventable reasons include use of an antibiotic with known high resistance in the community, poor patient compliance, and inadequate treatment of pain and nausea. The emergency clinician can reduce the preventable returns by reinforcing the need to take the full course of antibiotics, by prescribing according to local antibiotic stewardship programs and antibiograms, and by prescribing medications for pain and nausea control in addition to antibiotics at discharge. - “Her heart rate is still 120 beats/min, but that is just part of having a UTI. She will be fine.”
A certain percentage of patients will return, even with sepsis, after being appropriately diagnosed and treated. To decrease the risk of bounceback or occult sepsis, emergency clinicians are encouraged to resolve abnormal vital signs before discharge. Pyrexia should be treated. If the tachycardia is associated with dehydration, intravenous fluids should be administered. It should be clear to anyone reviewing the chart that the practitioner searched for and reasonably ruled out the presence of clinical sepsis. - “He has a positive urine dipstick, so my work here is complete.”
When performing a fever workup, it can be tempting to assume a diagnosis of UTI or pelvic inflammatory disease in a patient with a fever and trace or 1+ leukocytes. Particularly in the case of a patient with high fever, abnormal vital signs, or immunosuppression, it is important to consider other possibilities. The emergency clinician should also bear in mind that fever is relatively uncommon in isolated cystitis. Strategies to reduce risk include gathering history and physical examination information to rule out other causes of infection, catheterization of the urinary bladder to obtain a more reliable sample, and running a microscopic urinalysis to confirm the presence of leukocytes and rule out the presence of contamination. - “I didn't know that counted as a complicated UTI.”
UTIs will behave differently in different patients. It is important to consider the host patient as well. Has the patient been recently hospitalized or is the patient immunosuppressed? Does the patient have diabetes mellitus? Conditions that weaken the host should be considered. - “I didn't know appendicitis could cause pyuria.”
In the case of lower abdominal pain, the presence of trace or 1+ leukocytes can lead to premature closure in the evaluation of abdominal pain. Cystitis characteristically causes pain mostly with urination. Pyelonephritis characteristically presents with fever and flank pain (except in transplant patients where the tenderness will be over the graft site) and not with abdominal pain. When the inflamed appendix is close to the ureter, it can cause sterile pyuria. In patients with lower abdominal pain and trace or 1+ leukocytes on a urine dipstick, the diagnosis of appendicitis should be at least considered, and it should be clearly documented that the right lower quadrant is nontender if no more workup is to be done. - “She had lower abdominal pain and pyuria, so I didn't think a pelvic examination was indicated.”
With pelvic inflammatory disease or tubo-ovarian abscess, irritation of the bladder can also cause sterile pyuria. In women, the diagnosis of pelvic inflammatory disease or tubo-ovarian abscess should always be at least considered when lower abdominal pain and mild or minimal pyuria are present. It is recommended to establish and document that there are no concurrent pelvic symptoms in women with UTI. Pelvic examination may be warranted. - “History and physical examination are of diminished value in the modern age.”
Appendicitis, tubo-ovarian abscess, diverticulitis, nephrolithiasis, spinal epidural abscess, and pelvic inflammatory disease can mimic UTI. The key to picking these mimic cases is not so much in testing as it is in careful questioning and physical examination. - “I will not let antibiotic stewardship programs interfere with my practice.”
Antibiotic stewardship programs and local antibiograms, when present, are a valuable resource and represent the community standard of care. Treating according to a national application or booklet (which lack local antibiogram data or antibiotic stewardship program recommendation) is a second-line choice. In our community, adherence to antibiotic stewardship program recommendations and local antibiogram data have resulted in fewer treatment failures, fewer complications (such as C difficile infection), and, somewhat surprisingly, overall diminished resistance pattern across the board. In our institutions, practitioners who do not prescribe according to antibiotic stewardship program recommendations and do not document a reason for exception are subject to peer review. - “I just use the most broad-spectrum antibiotic, so my treatment never fails.”
It may be tempting to use the “biggest gun,” but it is not always best for the patient. Antibiotics with relatively high anaerobic bactericidal activity (such as amoxicillin clavulanate or levofloxacin) are seldom the first-line choice. By killing commensal organisms, they may increase the risk of C difficile infection. Additionally, antibiotics with extreme range but not a lot of strength in any single area (such as ciprofloxacin) are also considered second-line choices, not just because of resistance patterns, but because their weak activity against such a broad spectrum tends not to be bactericidal but to simply promote increased resistance across the board. Practice environments can be unique, and it is possible for fluoroquinolones to be first-line agents in some communities; it depends on the local antibiogram and the local antibiotic stewardship program recommendations.