Diagnosis & Treatment of Asymptomatic Bacteriuria in Adults- Dr. Ricardo Arbulu, 4/2/14

oh good afternoon welcome to Grand

Rounds today please remember to sign the

attendance record and also please

remember to fill out the program

evaluations and again ask you as I

always do to give us any ideas that you

might have in regards to future topics

and up future speakers today I have the

pleasure of reintroducing dr. Ricardo

rule our balloon doctor our Balu is

board certified in internal medicine and

also infectious disease and he in fact

is the department of infectious disease

at Mary Greeley and McFarland also the

most recent recipient of the Mary

Greeley excellence and innovation award

and he's here to update us on the

diagnosis and management of asymptomatic

bacteriuria and adults and please join

me in welcoming dr. baharlou

thank you everybody

thanks for coming well the title was

catchy right so we are not going to talk

about UTIs we're going to talk for the

next 45 minutes about this condition

called asymptomatic bacteriuria that is

not something that appears to be on

people's mouths too much as it needs to

be what motivates this talk is the issue

of antibiotic overuse this is a global

problem and I us in particular as you

probably know over utilizing antibiotics

is associated with the current CF

colitis epidemic that does include Mary

Greeley it's associated with increasing

and t-mike antimicrobial resistance

worldwide and of course it gets to the

whole issue of unnecessary care you

simply don't want to give medication

that does not to be in because

everything has side effects this was in

Fox News this month and what they were

discussing here is a following study CDC

puts out periodically a study or series

of studies called CDC's vital signs and

in March they happen to address the

issue of anti

overuse so in this stable they are

showing a survey that they did on a

convenience sample of 183 acute care

hospitals across the nation in which

they describe what are the most common

indications in a hospital to prescribe

antibiotics whether it's appropriate or


which are the most common lower

respiratory infections is number one and

UTIs is number two so of this 11,000

people 993 received antibiotics for UTI

so 13% of everybody who received

antibiotics received it for UTIs and

then they went on to try to guess how

much of that was appropriate at how much

was inappropriate and they came up with

39.6 or 40% of inappropriate use based

on which criteria things that seemed

pretty obvious right so well if you do

not order a urine culture how can we

tell that you have UTI right that's

pretty standard treatment practice and

so they counted those I'm sorry and this

is not the whole sample but more like a

sample within that does those 11,000

people they just randomly picked up 1100

I'm sorry

111 charts and these are the actual

absolute numbers of what they saw so

this is just a sample within that

obviously all the statistical means to

do this were respected and my point here

is what I have Circle here that a lot of

people had urine culture positive but

nowhere in the chart they could find

symptoms of UTI so you read this and it

seems logical yeah why did they get

antibiotics that's miss prescribing and

that was 20% well that has a name and

that's call a symptomatic bacteriuria so

this happens elsewhere right in happens

in 183 acute hospitals but doesn't

happen a mary greeley correct I want to

go over this case with you guys it's a


slights case but it's worth because it's

kind of an outline for the rest of the

talk so let's read through it and

there's a question at the end of course

depicting the challenges of this

situation so this was a 78 year old

female that came from an assisted living

she had diabetes mellitus type 2 which

was well controlled hypertension

hyperlipidemia COPD and urinary

incontinence all of which is kind of a

frequent combo she presented to the

emergency room with chest pain this this

Nia feeling poorly all over one day can

you hear me well okay temperature was

99.1 heart rate was 112 the exam was

unrevealing ordered an anxiety and she

did have a fluctuation or a peak in in

her troponin

so I'm trying to Hindu in that she did

have a known as the elevation MI the CT

angiogram done for to evaluate her chest

pain and this Nia was negative for

pulmonary embolism since she was

complaining of this nonspecific malaise

a urine analysis was ordered as urine

analysis reflect the urine culture if

abnormal and that's a common order in

the emergency room

since the urine analysis showed

leukocyte esterase positive and nitrates

positive the patient got a urine culture

reflected the microscopic you a dead


pyuria right cells leukocytes a little

bit of red blood cells and this goes

along with leukocyte esterase right

the patient was started empirically only

with fluxes in because they saw this

nitrates lucas's leukocyte esterase and

the white count and 36 hours later we

get this growth there's an e coli that

happens to E and E as VL so an extended

spectrum beta lactamase producer

susceptible to cefepime imipenem bactrim

and macro red everything else resistant

so the patient this is a follow-up at

that point at 36 hours her chest pain

has improved

she continues fatigue temperature was

normal she denies any urinary symptoms

she did not have CVA tenderness she's

allergic to sulfa I think I failed to

mention yeah she did have cardiac

catheterization so what is the next best

step in management and I want at this

point I would appreciate an honest

answer of you know you are here

listening about here in about acing the

matter bacteria you probably know what I

want you to answer but I want an honest

answer of if you got this such patient

in the middle of the night what would

you do for them and somebody's playing

with my computer here so I think you can

go ahead and answer now switch to one of

the antibiotics IV that she was

susceptible to switched to an oral

antibiotic which was susceptible to stop

and no antibiotics or consult ID

infectious diseases before anything is

done I'm getting 1920-21

and again honest answers kind of kindly

people are still clicking okay 27 will

allow one more go

okay so people honestly are saying they

would stop levofloxacin and you got a

hint from what I've been presenting that

that's a right answer so review of basic

things that are necessary to be able to

move forward when you get back there in

Korea right bacteria in the urine this

could be from pyelonephritis

so infection of the kidneys in which

case you would expect the patient to

have a combination of fever chills

nausea vomiting or an CVA tenderness of

course not usually the whole combo you

can have cystitis inflammation of the

bladder which typically goes with the

surya polyuria urinary frequency

willingness to urinate without being

able to urinary tenesmus

people do present with increasing

chronic incontinence

that's another actually frequent symptom

in elderly people of course you can have

a male reproductive tract syndrome that

it's a little bit outside of the scope

of the talk today but that's another

cause of positive urine cultures now you

could have none of the above you can

simply have a contaminated specimen

right so the patient needs to give you a

midstream vuoi that urine and that's

never a perfect process they need to

excuse me clean with well the genitals

and then give you a good sample so it

doesn't get dirty but there's a lot of

lots of opportunities for that sample to

get dirty the urinary Nieto's right here

is easily colonized the whole perineum

is with all the floral that comes from

the rectum and the anus from the vagina

as well and at times there's gross fecal

contamination people are fickle E or

incontinent of stool so there's a lot of

reasons why the urine can be

contaminated but when I'm introducing

today in case you're not familiar with

is that you can legitimately have

bacteria that comes from your urinary

tract the

in a bladder but does not cause symptoms

and that's another that differential

diagnosis of bacteria in the urine so if

we were to summarize what the infectious

diseases Society of America wants us to

know about this we go back to those

guidelines that were published in 2005

almost 10 years ago and haven't been

disputed basically because they have

good evidence backing them up anybody's

familiar with these guidelines raise of

hands kindly Leon doesn't count because

she's so one out of 100 people I'm not

sure how many are in the audience in

these are good quality guidelines

unlike most guidelines that the

infectious diseases Society of America

puts out because there's randomized

control trials backing it up

mostly guidelines come up when you know

we don't know there's no good evidence

yada yada this one it's pretty

straightforward and I think this is like

seis at all so how do you diagnosis

asymptomatic bacteriuria well no

symptoms of UTI Jed you get a positive

urine culture and the caveat here which

in practical terms you don't need to

worry about and I'll come back to this

is you need to have a colony count about

about certain diagnostic threshold right

to differentiate this from contamination

because I mean the logic is if you get a

little bit of bacteria there you can

assume that actually came from the

perineum or something but it if it comes

from the bladder or from the kidneys you

would expect a greater load of bacteria

and I apologize this didn't translate

well this is supposed to be 10 to the 5

so 100,000 colony is the typical number

that we are all used to here for

diagnosing pyelonephritis or societies

with a midstream voided urine the same

threshold applies to this but again in

most cases as we will see in this

particular case it suffices to know this

could be contamination and this or this

could be asymptomatic bacteriuria

I know I'm not going to treat either

I know this lady does not have societies

I know she does not have pyelonephritis

the management of such culture is the

following I mean we don't need to look

for it in the first place so do not go

screening people around for this and if

you find it simplement simp simply do

not treat it note this is not only of no

benefit but for many people is going to

be harmful needless to say is going to

be costly

except on big exception again backed up

by good evidence in these people

pregnant women they do need to be

treated if you find a urine culture

positive and patients who will go

your logic procedures with mucosal

injury the evidence actually is specific

for trans urethral resection of the

prostate but it's reasonable to

extrapolate to other procedures this is

not the focus of this talk because we're

we do well on this I mean people do well

on this across the board because this is

typically taken care of by gynecology

and urology respectively in a very

protocol lies fashion I mean they don't

need to think about it every pregnant

woman gets a urine culture and that gets

addressed seldom you will run them you

find a random urine culture done on

these people so what we are more more

interested in addressing is that other

population that gets random cultures for

various reasons and just to drive this

home again the thresholds exist mostly

to differentiate colonization from true

presence of the bacteria in the urine

we're just trying to guess by giving

these thresholds and this is very

important for research so they have a

unified definition and when we read

about asymptomatic bacteriuria and when

we present articles like I'm going to

present to you in a second we know that

we are talking about that and not and

we're not talking about colonization but

practically speaking you don't need to

worry about that for more for when you

encounter this cultures this little

table here is just depiction of how this

famous thresholds got generated the


that come up with this ten ten to the

five colonists which is kind of an

arbitrary threshold we're done in the

1950s and we're basically doing this

kind of a grid comparing or trying to

count how many or how many people who

get a first positive urine culture get a

second one what is the threshold for

getting a second one positive as you

mean that the term means that there's

true got Iranian so there's some study

for asymptomatic bacteriuria donut that

fat in that fashion in 1956 that term

was utilized by Cass who also came up

with the threshold that we are all

familiar with for pyelonephritis and

societies which happens to be the same

one another point to be made here is

that when you have a straight

catheterization for obvious reasons you

get a cleaner sample you are not that

demanding you do not want a threshold

that is that high if you find some

bacteria you assume it's real and that's

why we have a 10 to that 2.2 and not 10

to the 5 further the idea say for again

mostly for research purposes they

require two samples and that's what the

studies that I'm going to be quoting

mostly utilize so in addition to the

definition a main take-home message from

today is how frequent this is again

thanks to being able to diagnose a

cinematic bacteria we can find a

prevalence or two prevalence of this and

you can see here that even in

premenopausal women this is all women

without catheters in the urine because

that changes a whole game and I'll come

back to that women without any catheter

in with the following age groups and

conditions so premenopausal women they

would have anywhere between 1% and 5%

depending on the studies the definition

the specific populations studied that's

why you see a range and not a single

number because this is basically polled

studies over time pregnant women

overlaps probably slightly higher

when you get older you get more bacteria

and you can see that trend for people

over 70 around 15 percent of them have

bacteria and we're talking women at any

given time again these are all

asymptomatic people that were studied

for research purposes now look at this

when you get into a long-term care your

chances of getting bacteria are as high

as 50% in some studies and this goes

along with the fact that these people

are less functional so they get up less

they go to the bathroom less they have a

lot more bacteria accumulating in their

perineum which is more opportunity for

bacteria to crawl back and colonize the

bladder also they have a lot of

comorbidities that predispose them to

have bacteria growing in them and once

more these are all asymptomatic people

you can see I mean other common that can

be made here is the range here again we

give a range not a single number but see

how consistent the studies are in

several studies on and people greater

than 70 years of age in the community we

get always the same range when we get to

diabetics what we learn is that they

diabetic women have in general more

asymptomatic bacteriuria than their

counterparts that were not diabetics and

this large range that you see here is

because we're including diabetic women

of all ages that's it for the women know

I'm this is something very exciting and

may not be the whole story but it's a

very provoking explanation that

certainly has accounts for some of this

that we are seeing here so what research

has found by in this article by Clem

that very catchy was entitled mellowing


they find that there that that Europe

allergenic ecoli and a cinematic

bacteria e.coli

so here term you Peck specifically this

prototype with letters and the prototype

eight three nine seven two which is kind

of recurrent a cinematic bacteria bug in

the literature so they they found that

these are different animals literally

the gyro pathogenic a coli has adapted

to survive being essentially a parasite

it has developed timbre that allow it to

adhere to your bladder and to crawl

ascend into the kidneys it has mo lysine

that damages the epithelium so bacteria

are not evil beings they're just trying

to survive and this is a way that equal

I euro pathogenic has found its way to

survive in fact they can cross the blood

thanks to the schema lysine that

basically perforates the tissue and goes

through but the a cinematic bacteria has

mellowed out it's like you're grown up

child that doesn't want to move out and

has figured out that easier way to do

things right in and here it is so how do

we fight over that flow of urine that is

coming all the time we'll just chill

reproduce more frequently so more

bacteria says in the bladder we don't

need to go through a trial of a deer

into the hip epithelium we're just gonna

reproduce a lot and no need to to ascend

we'll just chill out in the bladder in

well of course when there's biofilm

there is another opportunity to stick

around with much without much effort

this is a beautiful study in this this

this is actually a copy pasted from the

original study and as we'll see is

probably not the whole story but it's

really really provoking certainly it has

been demonstrated that this is more

frequent in ants asymptomatic

bacteriuria and of course this is

typing that is not available in clinical

practice so back to our patient I think

people are convinced and probably you

guys were convinced the first time that

she has either a cinematic bacteria or

some colonisation because we didn't do

the exact criteria there I mean she

didn't have two different samples but we

know there's bacteria that are not

causing pile on Fridays and no societies

because she's not symptomatic treatment

is there for no antibiotics so people

may be wondering are you sure the

patient is diabetic and people may come

up with this very true fact UTI is more

frequent in diabetic than non-diabetic

women and it tends to be more severe we

have this pneumatosis on on the bladder

and all sorts of complications

what about having pyorrhea this woman

had 25 to 50 of white blood cells so

doesn't that mean that she is inflamed

and we need to take care of that and

finally I didn't make the point that we

found an es VL on that patient she had a

very aggressive I would say a very

resistant organism to treat that we

don't want to spread so the data that we

need to address that is a rain

randomized control trial to see well

treatment is beneficial or is it not

beneficial and they already did that and

that's part of a quality data that is

incorporated on this guidelines on 10

years ago so this group in Manitoba

Canada which is very active in study in

a symptomatic bacteria enrolled 19 or

screen rather 1900 adults greater than

16 years of age without any symptoms of

UTI they were attending a clinic for

diabetes so they screen them with the

two different cultures and 135 of them

made the criteria for a cinematic

bacteria and if you do the math that

coincides with the prevalence studies

that I just showed you the people were

randomized again all this is blind up to

that point

to receive to the treatment arm or to

the placebo arm in the treatment arm

what they did was something aggressive

that certainly is overkill for society's

as we know at this point they did back

to him or to cetera or ciprofloxacin for

14 days depending on allergies and

susceptibilities they rechecked the

urine at the end of those two weeks if

the patient was positive they retreated

if a patient was positive yet a third

time they said let's give them

prophylaxis and they did that for up to

36 months of the study lasted for

legitimate reasons many women were lost

to follow-up but I think this is still

quality data as I'm going to show in a

second the placebo arm was a real

placebo study so they gave them pills

that were identical to either the

American sulfur or the cipro and the

outcome barrel of the study was actually

see how many of these people actually

get UTIs that they can feel right

pyelonephritis or society so the use of

antibiotics for that indication was

rather than al comparable and that was

allowed in this women whenever it

happened so I think you can still see

these numbers but the bottom line is is

here to your right of the screen this is

stable one of the study and I want to

make sure people notice that these two

groups of 50 women in one arm of 55 on

the other arm were comparable in

relevant barrels so they were about the

same age we're talking about women

around 57 the same race they were

equivalent in their history of UTIs

history of gynecological surgery their

sexual activity glycemic control which

was by the way pretty bad here their

hemoglobin a1c was 32 point

I'm sorry thirteen point two in one arm

and twelve point seven and the other arm

which I think supports the notion that

well if somebody's gonna get UTI is this

women and they were also similar on what

organism was record so there was a coli

Klebsiella etc equal IV in the most

frequent as expect

so let me walk you through this result

table so as I said some women will also

follow up so it's important to notice

how long where they actually followed up

for the placebo people 790 some days the

this is by the way Express tone means

plus minus standard deviation okay so

that's why you get this plus minus and

another number here but you can see that

they were followed for over two years in

both arms and there was not a

significant difference when we do the

p-value so now let's look at the actual

results so how many events per 1000 days

of follow-up did these people have so if

you take all the symptomatic UTIs in the

placebo arm 1.1 per 1000 days and the

other arm 0.93 no significant difference

and that was repeated for societies

alone for pyelonephritis alone for any

UTI requiring hospitalization no

difference that you see here that

p-value is greater than 0.05 bottom line

you gave antibiotics to these people

here in the treatment arm for up to 36

moms and you achieved no difference on

the symptoms they felt on such societies

or pyelonephritis or they requirement

for hospitalization what was different

of course was how much antibiotic they

got the days of antibiotic use for UTI

for 1000 days and sorry this should say

in follow-up including the study

antibiotics of course we want to include

that so when you compare that of course

a placebo people well at times they did

get UTIs they get some antibiotics that

adds up to 33 days in 1000 days a follow

up whereas the other guys got 158 and

that's a remarkable significant

difference there were more side effects

in the treatment group the difference in

this small study was not significantly

different to drive at home we can look

at a survived

curb which shows you slightly different

data which is how many of the women

actually did not have symptomatic UTI at

any given time at the beginning nobody

had it because there were these were all

asymptomatic bacteriuria people and so

this is one hundred percent or one and

then with the months of course you

expect this to drop as many people do

fall to UTIs so as you see here this is

basically even out and you can argue the

antimicrobial therapy group was a

slightly better at the end of the

follow-up in over thirty months but when

you do the Isetta sickled analysis and

in that i'm trusting them because i

couldn't decipher the test use but

basically this number is no different

from this number so you gave antibiotics

all this time and achieve no difference

in preventing an actual UTI if you had

him screen these people if you hadn't

done anything

they wouldn't have felt anything so

conclusions and excuse me

antibiotic intervention did not reduce

the rate of subsequent UTI or the use of

antibiotics for the same in a cohort of

women of various ages but means

fifty-seven ages 57 years old excuse me

not shown in the table it's the time to

the first UTI so I mean you receive that

the aurochs of the beginning or you were

assigned to placebo the UTI occurred the

first UTI occurred around the same time

the guidelines are very clear there's no

role of create of screening diabetic

women for UTI

I know you need to get another urine

test there right and for micro

luminarias but make sure to either not

do a urine culture with that or if if

for some reason it gets done you don't

care about it right I mean that's what

that's what it needs to be done and

that's better care than done

taking care of that blood culture

between quotations so back to our

initial case people said well his she's

diabetic we should treat her I mean we

made that point we should not treat her

now how about that pyuria those white

blood cells typically that should in the

inflammation in your bladder we should

treat inflammation right well if you

look at patients the universe of

patients here are already all those

those patients who do have a symptomatic

bacteria again nobody's symptomatic in

this chart

among those how many have diarrhea and

you see that pyuria white blood cells in

the urine is fairly frequent the older

you get this is a recurrent theme as you

see the older you get the more likely to

get diarrhea the more morbid you are

overall the more likely you get to it

but diarrhea in people who have long

term catheters and I'll show you a

different graph depicting the same we

can assume that at one point in time

once at least 21 days of catheter have

gone by these people don't have all been

colonized and they all have bacteria

excuse me they will have pyorrhea we're

talking that we're looking at the white

blood cell counts at this point bottom

line by urea is frequent therefore it

doesn't help me decide whether this

people have something else bacteriuria a

synthetic bacteria comes quote-unquote

the combo comes with diarrhea most of

the time that's a message with this

slide the third argument that people

make is okay she had a resistant bug

what I mean do we I let it go and the

best evidence which is kind of indirect

but it's logical is looking at what is

the microbiology of UTI namely cystitis

and pyelonephritis and compare it to the

microalgae of a cinematic bacteria in it

is similar if you grab young adults they

have what most of them will have e coli

staph supper of it occurs is a common

cause relatively common cause of

cystitis in young women and then you

have your enteral bacterial CA

Enterococcus a streptococcus will be and

rarely add in that age group Pseudomonas

when they go the studies on a

symptomatic bacteria they rip replicate

this so there's really no difference

it's kind of the same box doing this in

my V just just to keep the consistency

here it might be that we have a mellow

version of each of this bug box we only

know that for e.coli we there's no

studies to date that I'm aware of that

would describe that they're species

exclusive to a cinematic bacteria love

this but the point in case is that

you're getting the same pattern that in

symptomatic UTI this is to depict older

adults and as you see as you get older

you trade some of your equal eye for

Pseudomonas and this is a question we

get frequent like I've been asked in

recent memory within the past week I

remember somebody asking me well they

got Pseudomonas that's rare right when

you get older is is not that rare and

you start picking up some polymicrobial

infections' you start seeing more than

one ball when it comes to catheters if

you have a long term catheter your equal

eye is no longer the king because it's

easier to get all sorts of blocks and

it's more it's easier to get

polymicrobial infections' bottom line

from all this the microbiology is the

same and therefore there's no that

wouldn't let you decide what to do with

that culture you have to look at the

syndrome we already show you good

evidence that a cinematic bacteria

doesn't do well or doesn't need to be

treated at least in that diabetic

patient population and I'm going to show

you Auto randomized control trials in a

second in one table now what happened to

this this this beautiful theory about

the mellow bug here being different than

this one

it seems that any bacteria can cause a

cinematic bacteria so the host appeared

to be more important than the pathogen

so again you see the same pattern in age

groups if you are young adult

you gonna get a UTI is gonna be eco life

you're gonna get a cintamani or three is

gonna be eco life and you were older

you're more likely to get a Pseudomonas

in niger syndrome we need to learn a lot

more about this but the point in case is

that this little interim summary here so

we're I think we we've talked this quite

a bit do not screen diabetics for the

evidence that we just presented

significant pyorrhea almost universal in

elderly patients with bacteria and in

other populations as frequent so it

doesn't help you differentiate it

doesn't give you any additional

information if you have a resistant

organism it doesn't really help you

distinguish whether you have excuse me

it doesn't help you distinguish whether

you have symptomatic UTI or a cinematic

bacteria what does help you distinguish

three things right symptoms symptoms and

symptoms where everything fails

interview and examine the patient that

leads us to case number two what if now

you get this 91 year old nursing home

resident who has severe AHA Alzheimer's

dementia who cannot refer history and

she has this history of recurrent UTIs

she's chronically incontinent of urine

she became agitated 24 hours ago and

she's trading in the stuff in the

nursing home her temperature is slightly

above her usual as you see there you are

told by the nursing home there's no

recent change on medication she's not

diabetic she does not have any other

major comorbidities they did go ahead

and do a dipstick which is positive for

leukocyte esterase the urine culture was

obtained right away and now it's 24

hours later she's still agitated you get

100,000 see a view of gram-negative rods

the daughter dropped by in the nursing

home earlier and she's sure the patient

has a UTI because this is what happens

to mom you're on call at 3 a.m. at Mary

Greeley Medical Center and this is I

mean this is a real patient but this is

adding a little spice to it because the


not a 3m and you get a call from the

nursing home requesting an antibiotic

how would you honestly proceed again ask

in your usual practice would you start

levofloxacin would you order - certainly

ofloxacin if the temperature is greater

than 99 you would do that so order if

the temperature is greater 99 + advise

hydration request request that the nurse

practitioners who round on our nursing

homes locally rounds on this woman

within the next 24 hours and then you

would document what you did an epic and

forward a note to the primary care

physician or you would do some of all

this nice combo but not all because it's

not realistic or you don't think it's

necessary and responses are still


okay we have 23 people we're gonna stop


so most people chose free obviously the

longest answer is because we wanted to

do that and seems logical right um

now um how how often does that really

happen I I visited with nurse

practitioners who take care of the

nursing homes Amy and I spoke to her

last week and part of her frustration is

when she goes back to see these patients

there's no documentation of what

happened overnight and understand that

we saw people are busy and whatnot so

there's one point of improvement there

and it helps keeping track of what

happens later we'll come back to that I

just wanted to make sense of this when

you're older you have more chances to

get a symptomatic bacteriuria because of

this reasons in males in basically the

prostate enlarges and you retain urine

in women the Austral estrogen depletion

causes bacteria to be more frequent in

this is the one in slide I had on men I

hadn't mentioned men before just to show

what is true pretty much for any age


the men would lag behind a little bit on

their frequency of bacteria but when you

get to this old age it's still high I

mean you can get up to 40 percent okay

that was a little X courses I'm gonna

skip this one to show you again back to

the point okay how do we deal with this

patient at 3 a.m. again

randomized control trials and we have

several of them that are here for your

review and this is in the guidelines

that showed repeatedly in several

populations of elderly people see that

average age of this study is 85 83 80 81

whether they are in the community or in

an institution they show that there is

no difference in symptomatic UTIs and in

order outcomes such as mortality when

you treat this versus not treating

so in the interest of time we won't

analyze each I went in detail or that

one randomized control trial so we get a

grasp of how good the evidence is some

of these though I should say I got a

chance to review they're not the

greatest studies we're talking about 50

to 55 people some of the outcomes are

probably not realistic like they try to

decide mortality based on one dose of

bactrim given a year ago so at least

there's some consistency in this data in

we have that powerful study on that

diabetics that I think is the one that I

would take us better evidence that a

cinematic bacteria is probably not a

threat so here's some tool that I would

like to share with you guys there's

nothing new this has been out since 2001

which kind of can serve as your

surrogate when evaluating those people

that cannot refer you symptoms so as we

said in our interim summary what you

need to decide where to treat them

another symptom symptoms symptoms but

these people cannot give you symptoms

they're confused they are demented so

there's criteria that by no means to the

best of my knowledge have been studied

prospectively or in randomized control

trials or whatnot but they are a

consensus of experts and same seem

reasonable that's the best we get too

late and this is already over ten years

old but you'll see many institutions

have this in their guidelines we're

talking about the lower or low lip I

think that's how you say it criteria so

let's start with without an in willing

catheter people who do not have an

indwelling catheter typically we

required a cardinal sin symptom whether

it is dis area or fever with the most

valuable input here that what we

consider fever on these people because

they are elderly is lower than what we

consider fever in otherwise younger

people and conveniently I mean this is

evidently not evidence driven because

it's such a nice round number 100 but I

guess it's a very fair

is there so fever is 100 and or

interestingly 1.5 degrees Celsius above

the baseline or 2.4 ferrand hit you can

find this enough to date this is

evidently a a copy based form up to date

and I will make it available as a dot

phrase in epic briefly after in the next

week so you can pull it up when you're

seeing these people so people at 3 in

the morning and again one Cardinal

syndrome plus one of the fallen near

worsen an urgency very frequent

frequency suprapubic pain gross

hematuria CVA tenderness urine

incontinence nowhere in here is

mentioned smelly urine which is the

number one reason for getting a urine

culture anywhere it is mentioned or in

this order older criteria that are a

little bit more cumbersome changing a

character of urine and in the small font

it considered you know how it looks how

it smells and yadda-yadda again this our

experts sitting down on the table and

trying to come up with something i think

the main message here is never use a

smelly urine as your one reason to check

incorporate it into this criteria you

can make a customized left criteria

there nursing home knowing your stuff

per patient per family this is I mean

guidelines are guidelines experts

opinions as experts opinions it's better

than me telling you what I think needs

to be done but we get to the evidence

free zone here and let me tell you what

I think needs to be done because and

this is based on my personal experience

in my time here so I think what the

intervention I think that that the

intervention that is most likely to help

this patient is nothing that you're

going to accomplish in that free am call

I mean it's unfair to put all the

pressure of antimicrobial stewardship on

that poor physician who's admitting 20

patients at that time what we want is to

be proactive

what we need is I propose it to do it

this way but what you want to gather is

the spirit of all this

a 30 to 60 minutes appointment that this

patient is to have with their primary

care physician you can utilize

infectious diseases such as your

research resource to have that in

presence of the daughter ideally in

presence of a nursing home staff and we

need to address the recurrent UTIs what

will we accomplish or what would we do

during that visit first of all does this

patient have UTI that's always the first

question why are urine cultures checked

on this patient identified other

triggers of her acute delirium or acute

problems that she's always having

basically do the good old-fashion HMP

that is relevant seize the opportunity

to educate the family and the staff on

this and finally come up with instead of

just copying this and sticking it on the

nursing home give this personalized for

the patient what in my experience that's

the one thing that works at the end you

reduce antibiotic usage by doing this

kind of approach it takes obviously a

lot of time in this days of managed care

and in these days of efficiency of care

etc we are progressively we will be

compensated by outcomes and not by the

procedures we do so prescribing more

antibiotics is more clearly going to be

not the option and this kind of thing

will be very humbly I present to you

with my epic template that I can share

with you in epic with a dot phrase but

these are the kind of things you want to

ask it would be nice to revise this with

urology and gynecology in all the adult

medicine doctors family medicine to come

up with the best high-yield

questions to ask kind of a checklist

approach and for those who tie their

notes this might be helpful we have four

minutes this I presented on my on a talk

on UTIs that we had two years ago there

is a very nice qualitative study where

they surveyed providers in focus groups

and these are some of the themes that

were identified

physicians over prescribed antibiotics

for UTI in I put a smiley on things that

we may have addressed today

so probably you have a better grasp of

what bacteriuria means what is

symptomatic and what is not sorry can

get rid of this the ordering of urine

culture for non specific changes in

resident status we gave you some kind of

objective data to go by hopefully

uncertainty physicians of all the

significance and management of positive

culture result hopefully we gave you

enough evidence on that and concerns

over lye liability now you know there's

good evidence backing things up nobody's

going to show you when there's a

guideline there with randomized control

trial saying this is what you need to do

last word catheterize patients when

patients get a catheter this is

basically what happens every day you

increase by two to seven percent your

rate of colonization so when you reach

21 days 100% of patients have bacteria

in their urine so keep that in mind when

you get the catheter rise patient who

people are suspect and they have a UTI

that needs to go into your analysis and

I was going to go back here patients

with with an indwelling catheter it's a

slightly different criteria you have

different thresholds of suspicion these

people get don't let me wrong we need to

treat these people I've got very sick

people with catheter associated sepsis

and bacteremia in fact that's the most

common cause of bacteremia in the

hospitals that is nosocomial and you

need to have a lower threshold for them

to treat them yet again it is common to

have bacteria with no problems in the

urine in in that population I'll leave

you with the summary that I could read

along but in the interest of time I want

I think the important points here is

that I want to introduce this proactive

approach here involving the family and

the nursing home to offload the burden

in the acute setting in the moment we

need to take the decision I'll leave you

with questions

if there's no questions I'm gonna yeah

thanks for the applause

something like dr. Brown gone because

he's the one who likes this kind of

thing for this is more folk folk were

walking now not with direct implications

for care but I was just reading about

this too soon a go to make it into the

Grand Rounds but somebody it occurred to

somebody to a PCR analysis of urine and

that was already 2012 they found that

almost 100% of random people had some

kind of bacteria in their urine detected

by PCR so this challenge is a whole

notion that we learned in medical school

or nursing school that you're in a

sterile urine is not sterile I think we

we've showed you how is not sterile with

bacteria that we can be tagged by normal

cultures but this whole PCR thing

molecular testing reveals a whole bunch

of other bacteria that we don't know

about we do not know what they're doing

there but it's reality our body's full

of bacteria good or bad they are there

thank you